Douglas M Wallen

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

019020653 Issued in IL

Practice address

2502 Galen Dr
Suite 103
Champaign, IL 61821-7045

Phone

(217) 366-0050

NPI assigned

Jul 11, 2008

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in IL

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1215734400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1215734400000",
    "number": "1407010176",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2502 GALEN DR",
            "address_2": "SUITE 103",
            "city": "CHAMPAIGN",
            "state": "IL",
            "postal_code": "618217045",
            "telephone_number": "217-366-0050"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2502 GALEN DR",
            "address_2": "SUITE 103",
            "city": "CHAMPAIGN",
            "state": "IL",
            "postal_code": "618217045",
            "telephone_number": "217-366-0050"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLEN",
        "first_name": "DOUGLAS",
        "middle_name": "M",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2008-07-11",
        "last_updated": "2008-07-11",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "IL",
            "license": "019020653",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Montyiona Walker
• Nathan R. Walker, M.D.
• Whitney A Walker, PT, DPT
• James Edward Wallace Jr., PA-C
• Kanisha Wallace
• Shawna Marie Waller, LCPC
• Taylor Waller
• Carol Lynn Gates Walling, M.ED, , COMS
• Taylor Wallis, LSW
• Walmart Inc.

• General Practice Dentistry in Champaign, IL
• Providers in Champaign, IL by specialty
• General Practice Dentistry in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 11, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.