Basic Information
Provider Information | |||||||||
NPI: | 1659314540 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WALDRON | ||||||||
FirstName: | KEVIN | ||||||||
MiddleName: | GERARD | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 840 TOWNE CENTER DR | ||||||||
Address2: |   | ||||||||
City: | POMONA | ||||||||
State: | CA | ||||||||
PostalCode: | 917675900 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9093981550 | ||||||||
FaxNumber: | 9093981488 | ||||||||
Practice Location | |||||||||
Address1: | 160 E ARTESIA ST STE 220 | ||||||||
Address2: |   | ||||||||
City: | POMONA | ||||||||
State: | CA | ||||||||
PostalCode: | 917672921 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9098651020 | ||||||||
FaxNumber: | 9098651202 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/14/2006 | ||||||||
LastUpdateDate: | 09/13/2018 | ||||||||
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 | 207T00000X | 036.113732 | IL | N |   | Allopathic & Osteopathic Physicians | Neurological Surgery |   | 207T00000X | 01060759A | IN | N |   | Allopathic & Osteopathic Physicians | Neurological Surgery |   | 207T00000X | C147602 | CA | Y |   | Allopathic & Osteopathic Physicians | Neurological Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 129164100 | 01 | IN | INDIANA DEPT OF LABOR | OTHER | P00298697 | 01 | IN | PALMETTO RR MEDICARE | OTHER | 0375788 | 01 | IN | ANTHEM | OTHER | 200800980 | 05 | IN |   | MEDICAID |