Basic Information
| Provider Information | |||||||||
| NPI: | 1710996996 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLER | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | HENLE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 S UNIVERSITY AVE | ||||||||
| Address2: | SUITE 316 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722055302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016039600 | ||||||||
| FaxNumber: | 5016030042 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 S UNIVERSITY AVE | ||||||||
| Address2: | SUITE 316 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722055302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016039600 | ||||||||
| FaxNumber: | 5016030042 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | E0253 | AR | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 04828 | 01 | HEALTHSOURCE | OTHER | 16047000000 | 01 | QUALCHOICE | OTHER | 7420056 | 01 | UNITED HEALTHCARE | OTHER | 125849001 | 05 | AR | MEDICAID | 71082800072205AO | 01 | TRICARE WPS | OTHER | 137315002 | 05 | AR | MEDICAID |