Organization
SIMEON H. WALL, MD A PROFESSIONAL MEDICAL CORP
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. SIMEON HENINGER WALL SR. M.D. (OWNER)
(318) 795-0801
Entity
Organization
Contact information
Practice address
8600 FERN AVE, SHREVEPORT, LA 71105-5639
(318) 795-0801
(318) 795-9492
Mailing address
8600 FERN AVE, SHREVEPORT, LA 71105-5639
(318) 795-0801
(318) 795-9492
Taxonomy
Speciality
Code
Description
License number
State
208200000X
Plastic Surgery Physician
Primary
02970R
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
115649
—
LA
Enumeration date
10/30/2012
Last updated
10/30/2012
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