1790214013 NPI number — GEORGE JOSEPH WALDENMAIER MD, MPHTM

Table of content: GEORGE JOSEPH WALDENMAIER MD, MPHTM (NPI 1790214013)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790214013 NPI number — GEORGE JOSEPH WALDENMAIER MD, MPHTM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALDENMAIER
Provider First Name:
GEORGE
Provider Middle Name:
JOSEPH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD, MPHTM
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:
1790214013
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
NAVAL MEDICAL CIR 34800 BOB WILSON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92134-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-532-6827
Provider Business Mailing Address Fax Number:
619-532-7508

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
NAVAL MEDICAL CIR 34800 BOB WILSON DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92134-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-532-6827
Provider Business Practice Location Address Fax Number:
619-532-7508
Provider Enumeration Date:
06/08/2017

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: 171000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: VAD0000 . This is a "MEDICARE UPIN" identifier . This identifiers is of the category "OTHER".




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