Basic Information
| Provider Information | |||||||||
| NPI: | 1851465801 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GARY D WALDMAN MD PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10512 PARK RD | ||||||||
| Address2: | SUITE 113 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282108469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045428018 | ||||||||
| FaxNumber: | 7045427147 | ||||||||
| Practice Location | |||||||||
| Address1: | 10512 PARK RD | ||||||||
| Address2: | SUITE 113 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282108469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045428018 | ||||||||
| FaxNumber: | 7045427147 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 04/03/2012 | ||||||||
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| AuthorizedOfficialLastName: | FORBIS | ||||||||
| AuthorizedOfficialFirstName: | WENDY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7045428018 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | CD7109 | 01 | NC | RAILROAD MEDICARE | OTHER | 0172L | 01 | BLUE CROSS BLUE SHIELD | OTHER |