Mark Waller, PT

Primary specialty

Physical TherapistTaxonomy code 225100000X

License

16250 Issued in FL

Practice address

11742 Eros Rd
Lehigh Acres, FL 33971-3759

Phone

(239) 671-8962

NPI assigned

Jun 9, 2022

Last updated

Jun 9, 2022By the provider in NPPES

Sex

Male

Sole proprietor

No

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 FL

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

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.

• Legacy Healthcare Services, Inc

  • Physical Therapist
  • Tampa, FL
  • NPI 1336535988
  Medicare reassignment NPD
• Legacy Healthcare Services Inc

  • Physical Therapist
  • Cary, NC
  • NPI 1225879489
  NPD

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

{
    "created_epoch": "1654732800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1654732800000",
    "number": "1801525381",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11742 EROS RD",
            "city": "LEHIGH ACRES",
            "state": "FL",
            "postal_code": "339713759",
            "telephone_number": "239-671-8962"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11742 EROS RD",
            "city": "LEHIGH ACRES",
            "state": "FL",
            "postal_code": "339713759",
            "telephone_number": "239-671-8962"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLER",
        "first_name": "MARK",
        "credential": "PT",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2022-06-09",
        "last_updated": "2022-06-09",
        "certification_date": "2022-06-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "FL",
            "license": "16250",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Wal-Mart Stores East, LP (Vision Center 30-2237)
• Walberto Taxi LLC
• Walgreen Co (Walgreens #06071)
• Wallace Family Practice PA
• Robert Vernon Wallace, M. D.
• Marie Rose Walters
• Victoria Marie Ward, COTA/L
• Jovial Watson, PHARMD
• Wawa Express LLC
• Chyann Marie Weber

• Physical Therapist in Lehigh Acres, FL
• Providers in Lehigh Acres, FL by specialty
• Physical Therapist in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 9, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.