JACK D WALLER (NPI# 1710980057) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1710980057 |
| Entity Type | Individual |
| Full Name | JACK D WALLER |
| Credential | MD |
| Practice Address |
1400 S Coulter St Amarillo TX 79106-1786 |
| Mailing Address |
1400 Wallace Blvd Attn: Credentialing Dept. Amarillo TX 79106-1708 |
| Practice Telephone | 8063545660 |
| Practice Fax Number | 8063545717 |
| Mailing Telephone | 8063545585 |
| Mailing Fax Number | 8063564673 |
| Enumeration Date | 2005-05-31 |
| Last Update Date | 2011-10-13 |
| Gender Code | M |
| Is Sole Proprietor | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| N | 174400000X | Specialist | Other Service Providers | ||
| Y | 207N00000X | Dermatology | D5242 | TX | Allopathic & Osteopathic Physicians |
| State | Issuer | Identifier | Type Code |
|---|---|---|---|
| OK | 100164990A | 05 | |
| TX | MEDICARE RAILROAD | 070002899 | 01 |
| TX | BLUE CROSS BLUE SHIELD | 807983 | 01 |
| NM | 22379835 | 05 | |
| TX | 037629501 | 05 | |
| TX | 037629502 | 05 |
| Street Address |
1400 S COULTER ST |
| City | AMARILLO |
| State | TX |
| Zip Code | 79106-1786 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1992311385 | Karlyn Hood | Pharmacist | 1400 S Coulter St, Amarillo, TX 79106-1786 | 2020-09-21 |
| 1083225866 | Roa Ali Eliyan Bashtawi | Student in an Organized Health Care Education/Training Program | 1400 S Coulter St, Amarillo, TX 79106-1786 | 2020-08-13 |
| 1063040020 | Mohammed Adib Tanbir | Student in an Organized Health Care Education/Training Program | 1400 S Coulter St, Amarillo, TX 79106-1786 | 2020-03-27 |
| 1558998898 | Joshua Anthony Sorenson | Student in an Organized Health Care Education/Training Program | 1400 S Coulter St, Amarillo, TX 79106-1786 | 2020-03-26 |
| 1740815943 | Udhaya Aelety | Student in an Organized Health Care Education/Training Program | 1400 S Coulter St, Amarillo, TX 79106-1786 | 2020-03-08 |
| 1831720341 | Nicole Moreno | Pharmacist | 1400 S Coulter St, Amarillo, TX 79106-1786 | 2020-02-03 |
| 1891347399 | Baptist Saint Anthony Health System | Student in an Organized Health Care Education/Training Program | 1400 S Coulter St, Amarillo, TX 79106-1786 | 2019-07-15 |
| 1134771645 | Daniyah Ali Elagi | Student in an Organized Health Care Education/Training Program | 1400 S Coulter St, Amarillo, TX 79106-1786 | 2019-07-15 |
| 1861055782 | Jankikeerthika Muthukaruppan Dharmarpandi | Student in an Organized Health Care Education/Training Program | 1400 S Coulter St, Amarillo, TX 79106-1786 | 2019-04-16 |
| 1659834000 | Jacob Richard Hall | Student in an Organized Health Care Education/Training Program | 1400 S Coulter St, Amarillo, TX 79106-1786 | 2019-04-11 |
| Find all providers in the same location | ||||
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1538773205 | Nisha Patel | Pharmacist | 1600 S Western Street, Amarillo, TX 79106 | 2020-09-01 |
| 1043851769 | Diana Moore | Pharmacist | 6010 Amarillo Blvd W (119), Amarillo, TX 79106 | 2019-10-03 |
| 1164988127 | Wade Family Services Pllc | Counselor | 1901 Medi Park Dr Suite 130, Amarillo, TX 79106 | 2019-02-14 |
| 1255802963 | Jennifer Cockrum | Hospitalist | Bsa Hospitalist, 1600 Wallace Blvd., Amarillo, TX 79106 | 2018-12-07 |
| 1346736691 | Denise Mills Donnell | Social Worker | 6010 Amarillo Bouldevard West Clc-b, Amarillo, TX 79106 | 2018-07-10 |
| 1124525472 | Abigail Batson | Student in an Organized Health Care Education/Training Program | 1400 S Coulter Street, Suite 1500, Amarillo, TX 79106 | 2018-04-11 |
| 1053812743 | Moc Amarillo, LLC | Skilled Nursing Facility | 1540 Research St., Amarillo, TX 79106 | 2018-02-27 |
| 1013459437 | Larry G. Schulz | Durable Medical Equipment & Medical Supplies | 1901 Medi Park Dr Ste 219, Amarillo, TX 79106 | 2016-11-16 |
| 1922453315 | Omar Saeed M Alzhrani | Student in an Organized Health Care Education/Training Program | 1400 S. Coulter - Suite 5100, Amarillo, TX 79106 | 2016-05-04 |
| 1972967529 | David Wayne Hohon | Internal Medicine | Bsa Physician Group, 1600 Wallace Blvd., Amarillo, TX 79106 | 2016-04-11 |
| Find all providers in zip 79106 | ||||
| Taxonomy Code | 207N00000X |
| Grouping | Allopathic & Osteopathic Physicians |
| Classification | Dermatology |
| A dermatologist is trained to diagnose and treat pediatric and adult patients with benign and malignant disorders of the skin, mouth, external genitalia, hair and nails, as well as a number of sexually transmitted diseases. The dermatologist has had additional training and experience in the diagnosis and treatment of skin cancers, melanomas, moles and other tumors of the skin, the management of contact dermatitis and other allergic and nonallergic skin disorders, and in the recognition of the skin manifestations of systemic (including internal malignancy) and infectious diseases. Dermatologists have special training in dermatopathology and in the surgical techniques used in dermatology. They also have expertise in the management of cosmetic disorders of the skin such as hair loss and scars and the skin changes associated with aging. |
| Notes: Source: American Board of Medical Specialties, 2007. www.abms.org [7/1/2007: added definition, added source] Additional Resources: American Board of Dermatology, 2007. http://www.abderm.org/ Board certification is provided by the American Board of Dermatology. |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1609055128 | William R. East Md, P.a. | Dermatology | 5211 W 9th Ave Ste 103, Amarillo, TX 79106-4149 | 2007-10-31 |
| 1275588964 | William Robert East | Dermatology | 1901 Medi-park, Suite 6, Amarillo, TX 79106-2105 | 2006-05-23 |
| 1902803976 | Edward Michael Mccarthy | Dermatology | 4512 Van Winkle Dr, Amarillo, TX 79119 | 2005-07-05 |
| 1376811372 | Elaine Remmers Cook | Dermatology | 2609 Wolflin Vlg, Amarillo, TX 79109-1838 | 2011-12-05 |
| 1083932107 | Jason Kyle Jones | Dermatology | 4302 Wolflin Ave, Amarillo, TX 79106-5959 | 2010-05-13 |
| 1275858433 | Christi Anne Baker | Dermatology | 4302 Wolflin Ave, Amarillo, TX 79106-5959 | 2010-03-31 |
| 1609965862 | James Keith Yeary | Dermatology | 6010 W Amarillo Blvd, Amarillo, TX 79106-1990 | 2006-10-12 |
| 1265441513 | Evelyn Archer Mdpa | Dermatology | 1900 S Coulter St, Unit B, Amarillo, TX 79106-1784 | 2006-08-05 |
| 1740226687 | M. Elizabeth Archer Md Pa | Dermatology | 1900 S Coulter St, Unit B, Amarillo, TX 79106-1784 | 2006-06-21 |
| 1790722916 | Scott D Miller | Dermatology | 4302 Wolflin Ave, Amarillo, TX 79106-5959 | 2006-05-31 |
| Find all providers in AMARILLO | ||||
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| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.