Basic Information
Provider Information | |||||||||
NPI: | 1912990094 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WALDRIP | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | C | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 12361 W BOLA DR | ||||||||
Address2: | STE 100 | ||||||||
City: | SURPRISE | ||||||||
State: | AZ | ||||||||
PostalCode: | 853789021 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6235845626 | ||||||||
FaxNumber: | 6235449122 | ||||||||
Practice Location | |||||||||
Address1: | 12361 W BOLA DR | ||||||||
Address2: | SUITE 100 | ||||||||
City: | SURPRISE | ||||||||
State: | AZ | ||||||||
PostalCode: | 853789021 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6235845626 | ||||||||
FaxNumber: | 6235449122 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/24/2005 | ||||||||
LastUpdateDate: | 10/12/2011 | ||||||||
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 | 207X00000X | 13525 | AZ | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 1912990094 | 01 | AZ | AHCCCS | OTHER | 1912990994 | 01 |   | BC/BS AZ OUT OF AREA | OTHER | 730511 | 01 | AZ | UNITED HEALTHCARE | OTHER | 2Z3248 | 01 | AZ | HEALTH NET | OTHER | 256083 | 05 | AZ |   | MEDICAID | 5124334 | 01 | AZ | AETNA | OTHER | AZ0334260 | 01 | AZ | BCBS BLUECARD PROGRAM | OTHER | 256083 | 01 |   | AHCCCS | OTHER | 200006477 | 01 |   | RAILROAD MEDICARE | OTHER |