Provider Demographics
NPI:1043233596
Name:WALDER, MARY ELLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY ELLEN
Middle Name:
Last Name:WALDER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2041 N ROUTE 9
Mailing Address - Street 2:
Mailing Address - City:CAPE MAY COURT HOUSE
Mailing Address - State:NJ
Mailing Address - Zip Code:08210-1162
Mailing Address - Country:US
Mailing Address - Phone:609-624-8986
Mailing Address - Fax:660-962-4909
Practice Address - Street 1:2041 N ROUTE 9
Practice Address - Street 2:
Practice Address - City:CAPE MAY COURT HOUSE
Practice Address - State:NJ
Practice Address - Zip Code:08210-1162
Practice Address - Country:US
Practice Address - Phone:609-624-8986
Practice Address - Fax:609-624-9098
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-043998-E208000000X
NJ25MA09301700208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016092820004Medicaid
NJ0380491Medicaid
NJ0380491Medicaid
PAE69431Medicare UPIN