Provider Demographics
NPI:1053592840
Name:WALLER, WILLIAM LOWE III (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:LOWE
Last Name:WALLER
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-579-3130
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:3 THOMPSON PARK
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-8202
Practice Address - Country:US
Practice Address - Phone:601-579-3130
Practice Address - Fax:601-264-5092
Is Sole Proprietor?:No
Enumeration Date:2007-11-20
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.201654207N00000X
MS21371207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS9789697OtherAETNA
MS05471708Medicaid
MSP01087225OtherRAILROAD MEDICARE
MS302I076777Medicare PIN