Provider Demographics
NPI:1063673879
Name:NIKKI A WALDEN MD PA
Entity Type:Organization
Organization Name:NIKKI A WALDEN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-820-9333
Mailing Address - Street 1:PO BOX 118383
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75011-8383
Mailing Address - Country:US
Mailing Address - Phone:972-820-9333
Mailing Address - Fax:
Practice Address - Street 1:4325 N JOSEY LN
Practice Address - Street 2:300
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-4635
Practice Address - Country:US
Practice Address - Phone:972-820-9333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-24
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8999174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4732959OtherCIGNA
TX16244OtherPARKLAND
TX4501037598OtherCLIA
TX0066MHOtherBLUE CROSS BLUE SHIELD
TX173131701Medicaid
TX4732959OtherCIGNA
TXI17011Medicare UPIN