Basic Information
| Provider Information | |||||||||
| NPI: | 1184674822 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALDER | ||||||||
| FirstName: | LON | ||||||||
| MiddleName: | ANDREW | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1308E PALUXY RD | ||||||||
| Address2: | |||||||||
| City: | GRANBURY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760485689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175783904 | ||||||||
| FaxNumber: | 8175788903 | ||||||||
| Practice Location | |||||||||
| Address1: | 1308E PALUXY RD | ||||||||
| Address2: | |||||||||
| City: | GRANBURY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760485689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175783904 | ||||||||
| FaxNumber: | 8175788903 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 02/29/2012 | ||||||||
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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 | 207RC0000X | J3931 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | J3931 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 136086909 | 05 | TX | MEDICAID | 1360869-05 | 05 | TX | MEDICAID | 86462K | 01 | TX | BCBS | OTHER | 1360869-02 | 05 | TX | MEDICAID | 4376993 | 01 | TX | AETNA PROVIDER ID | OTHER |