1568896256 NPI number — DR. DAVID PHILIP WALDEN ED.D., LICENSED ADDI

Table of content: DR. DAVID PHILIP WALDEN ED.D., LICENSED ADDI (NPI 1568896256)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568896256 NPI number — DR. DAVID PHILIP WALDEN ED.D., LICENSED ADDI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALDEN
Provider First Name:
DAVID
Provider Middle Name:
PHILIP
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
ED.D., LICENSED ADDI
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568896256
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/29/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3018 OLD MINDEN RD
Provider Second Line Business Mailing Address:
SUITE 1108
Provider Business Mailing Address City Name:
BOSSIER CITY
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71112
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-465-3849
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3018 OLD MINDEN RD
Provider Second Line Business Practice Location Address:
SUITE 1108
Provider Business Practice Location Address City Name:
BOSSIER CITY
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-465-3849
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/29/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  418 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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