Provider Demographics
NPI:1023030038
Name:DIANE WALDER MDPA
Entity Type:Organization
Organization Name:DIANE WALDER MDPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-866-2177
Mailing Address - Street 1:1111 KANE CONCOURSE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BAY HARBOR ISLANDS
Mailing Address - State:FL
Mailing Address - Zip Code:33154-2029
Mailing Address - Country:US
Mailing Address - Phone:305-866-2177
Mailing Address - Fax:305-866-5302
Practice Address - Street 1:1111 KANE CONCOURSE
Practice Address - Street 2:SUITE 100
Practice Address - City:BAY HARBOR ISLANDS
Practice Address - State:FL
Practice Address - Zip Code:33154-2029
Practice Address - Country:US
Practice Address - Phone:305-866-2177
Practice Address - Fax:305-866-5302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME74763174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE52383Medicare ID - Type Unspecified
FLG74292Medicare UPIN