Basic Information
| Provider Information | |||||||||
| NPI: | 1689783631 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALDRON | ||||||||
| FirstName: | VINCENT | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M. D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 W LONGEST ST | ||||||||
| Address2: | PO BOX 270 | ||||||||
| City: | PAOLI | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474548821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8127233944 | ||||||||
| FaxNumber: | 8127235292 | ||||||||
| Practice Location | |||||||||
| Address1: | 104 CAROLINA AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKNEAL | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245282643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4343762325 | ||||||||
| FaxNumber: | 4343762081 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 01/09/2018 | ||||||||
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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 | 207Q00000X | 0101259872 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200292510A | 05 | IN | MEDICAID |