Basic Information
| Provider Information | |||||||||
| NPI: | 1942731955 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLING | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | CLINTON | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 ROSE ST # C-246 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405360293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593236162 | ||||||||
| FaxNumber: | 8592578934 | ||||||||
| Practice Location | |||||||||
| Address1: | UNIVERSITY OF KENTUCKY 800 ROSE STREET | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593232636 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2017 | ||||||||
| LastUpdateDate: | 07/08/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 56880 | KY | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.