Active NPI
James D Waller Jr., MD
- Colon & Rectal Surgery Physician
- Evansville, IN
National Provider Identifier
1366440299
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Colon & Rectal Surgery Physician
- License
- 01029847A
- Practice address
- 950 S Kenmore Dr Ste B
Evansville, IN 47714-7513 - Phone
- (812) 301-8110
- Fax
- (812) 401-4001
- NPI assigned
- Jul 13, 2005
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Colon & Rectal Surgery Physician | 208C00000X | 01029847A | IN | Primary |
Addresses
Primary practice location
950 S Kenmore Dr Ste B
Evansville, IN 47714-7513
Mailing address
950 S Kenmore Dr Ste B
Evansville, IN 47714-7513
Phone (812) 301-8110
Other practice location 1
801 Saint Marys Dr
Suite 205W
Evansville, IN 47714-0511
Phone (812) 477-6103
Other identifiers 4
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 01029847A | Other | IN | STATE LICENSE |
| 000000042443 | Other | IN | ANTHEM BC/BS |
| 100352100 | Medicaid | IN | |
| 64757446 | Medicaid | KY |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1121212800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1555286400000",
"number": "1366440299",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "950 S KENMORE DR STE B",
"city": "EVANSVILLE",
"state": "IN",
"postal_code": "477147513",
"telephone_number": "812-301-8110",
"fax_number": "812-401-4001"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "950 S KENMORE DR STE B",
"city": "EVANSVILLE",
"state": "IN",
"postal_code": "477147513",
"telephone_number": "812-301-8110",
"fax_number": "812-401-4001"
}
],
"practiceLocations": [
{
"address_1": "801 Saint Marys Dr",
"address_2": "Suite 205W",
"address_purpose": "LOCATION",
"city": "Evansville",
"state": "IN",
"postal_code": "477140511",
"country_code": "US",
"telephone_number": "812-477-6103",
"fax_number": "812-477-4897",
"country_name": "United States",
"address_type": "DOM"
}
],
"basic": {
"last_name": "WALLER",
"first_name": "JAMES",
"middle_name": "D",
"name_prefix": "Dr.",
"name_suffix": "Jr.",
"credential": "MD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2005-07-13",
"last_updated": "2019-04-15",
"status": "A"
},
"taxonomies": [
{
"code": "208C00000X",
"taxonomy_group": "",
"desc": "Colon & Rectal Surgery",
"state": "IN",
"license": "01029847A",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "STATE LICENSE",
"identifier": "01029847A",
"state": "IN"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "ANTHEM BC/BS",
"identifier": "000000042443",
"state": "IN"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "100352100",
"state": "IN"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "64757446",
"state": "KY"
}
],
"endpoints": [],
"other_names": []
}Other providers in Evansville, IN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 15, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.