Basic Information
| Provider Information | |||||||||
| NPI: | 1780611806 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALL | ||||||||
| FirstName: | VIK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1717 MAIN ST | ||||||||
| Address2: | SUITE 5300 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752014605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2147122074 | ||||||||
| FaxNumber: | 2147122487 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 W 4TH ST | ||||||||
| Address2: | |||||||||
| City: | ODESSA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797615001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4326401190 | ||||||||
| FaxNumber: | 4326403489 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2006 | ||||||||
| LastUpdateDate: | 09/01/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | H1675 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8BB102 | 01 | TX | BCBSTX PROV. NO. | OTHER | 137851513 | 05 | TX | MEDICAID | 137851520 | 05 | TX | MEDICAID |