Kenneth Russell Waller III, DVM, MS

Primary specialty

VeterinarianTaxonomy code 174M00000X

License

6054 Issued in WI

Practice address

2015 Linden Dr
Room 2058
Madison, WI 53706-1100

Phone

(608) 263-7656

NPI assigned

Jul 25, 2012

Sex

Male

Sole proprietor

No

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

Specialties & licenses 3

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Credentials

Master of Science

State licenses

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

{
    "created_epoch": "1343174400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1343174400000",
    "number": "1841546959",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2015 LINDEN DR",
            "address_2": "ROOM 2058",
            "city": "MADISON",
            "state": "WI",
            "postal_code": "537061100",
            "telephone_number": "608-263-7656"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2015 LINDEN DR",
            "address_2": "ROOM 2058",
            "city": "MADISON",
            "state": "WI",
            "postal_code": "537061100",
            "telephone_number": "608-263-7656"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLER",
        "first_name": "KENNETH",
        "middle_name": "RUSSELL",
        "name_prefix": "Dr.",
        "name_suffix": "III",
        "credential": "DVM, MS",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2012-07-25",
        "last_updated": "2012-07-25",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "174M00000X",
            "taxonomy_group": "",
            "desc": "Veterinarian",
            "state": "WI",
            "license": "6054",
            "primary": true
        },
        {
            "code": "174M00000X",
            "taxonomy_group": "",
            "desc": "Veterinarian",
            "state": "IA",
            "license": "7379",
            "primary": false
        },
        {
            "code": "174M00000X",
            "taxonomy_group": "",
            "desc": "Veterinarian",
            "state": "IL",
            "license": "090010797",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Savannah Wallace, FNP-BC, APNP
• Sumer Kay Wallace, MD
• Suzanne Beth Wallace, APRN,BC
• Tara Wallace
• Ellis P Waller Jr., MD
• Thomas R Waller
• Thomas R Wallhaus, MD
• Kymm Ann Wallin
• Robyn Suzanne Wallin, LCSW
• Jessica Anne Wallis-Bhyravabotla, FNP-C

• Veterinarian in Madison, WI
• Providers in Madison, WI by specialty
• Veterinarian in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 25, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.