NPIMap

Individual provider Active NPI

Brian Bolivar Walls, MD

  • Internal Medicine Physician
  • Merritt Island, FL
National Provider Identifier
1508866237
Registry record updated Jul 3, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
License
ME71812 Issued in FL
Practice address
500 Crockett Blvd
Merritt Island, FL 32953-5034
Phone
(321) 243-8593
NPI assigned
Jul 22, 2005
Last updated
Jul 3, 2024By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jul 3, 2024

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine Physician 207R00000X ME71812 FL Primary

Addresses

Primary practice location

500 Crockett Blvd
Merritt Island, FL 32953-5034

Mailing address

PO Box 540033
Merritt Island, FL 32954-0033
Phone (321) 243-8593

Other identifiers 1

IdentifierTypeStateIssuer
251358700MedicaidFL

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20100607000890 FL Practitioner - Internal Medicine 5698805331 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Internal Medicine
Education
Howard University College of Medicine, 1990
Medicare assignment
Accepts the Medicare-approved amount as payment in full

Practice addresses (Care Compare)

500 Crockett Blvd
Merritt Island, FL 32953-5034
Phone (321) 454-4035

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
ME71812FLMDInternal Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Brian B Walls MD PLLC Internal Medicine CurrentSince Mar 1, 2017 Accepting new patients
Patrick K Brueggeman DPM LLC Past Accepting new patients
On Site Dermatology LLC Past Accepting new patients

Locations

3033 Sarno Rd
Melbourne, FL 32934
Phone (321) 243-8593

125 Alma Blvd
Merritt Island, FL 32953
Phone (321) 453-0202

500 Crockett Blvd
Merritt Island, FL 32953
Phone (321) 454-4035

Organizations & group practices 3

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 9

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

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

{
    "created_epoch": "1121990400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1719964800000",
    "number": "1508866237",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 540033",
            "city": "MERRITT ISLAND",
            "state": "FL",
            "postal_code": "329540033",
            "telephone_number": "321-243-8593",
            "fax_number": "321-453-6280"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "500 CROCKETT BLVD",
            "city": "MERRITT ISLAND",
            "state": "FL",
            "postal_code": "329535034",
            "telephone_number": "321-243-8593"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLS",
        "first_name": "BRIAN",
        "middle_name": "BOLIVAR",
        "name_prefix": "Dr.",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2005-07-22",
        "last_updated": "2024-07-03",
        "certification_date": "2024-07-03",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "FL",
            "license": "ME71812",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "251358700",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Merritt Island, FL

Sources for this page

Verify at the official NPI Registry.