Basic Information
Provider Information | |||||||||
NPI: | 1568431658 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WALD | ||||||||
FirstName: | DAVID | ||||||||
MiddleName: | ALAN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2450 W HUNTING PARK AVE | ||||||||
Address2: | FL 3 | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191291302 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2157075030 | ||||||||
FaxNumber: | 2157073494 | ||||||||
Practice Location | |||||||||
Address1: | 3401 N BROAD STREET | ||||||||
Address2: | TEMPLE UNIVERSITY HOSPITAL | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 19140 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2157075030 | ||||||||
FaxNumber: | 2157073494 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/14/2006 | ||||||||
LastUpdateDate: | 04/20/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | OS008297L | PA | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 888069 | 01 | PA | HIGHMARK BS | OTHER | 0096458000 | 01 | PA | INDEPENDENCE BC | OTHER | 0015536410008 | 05 | PA |   | MEDICAID |