Provider Demographics
NPI:1093785651
Name:WALDRON, BRIAN J (DO)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:J
Last Name:WALDRON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 BROADWAY
Mailing Address - Street 2:STE 910
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10006-2736
Mailing Address - Country:US
Mailing Address - Phone:212-344-5361
Mailing Address - Fax:212-514-5460
Practice Address - Street 1:61 BROADWAY
Practice Address - Street 2:STE 910
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10006-2736
Practice Address - Country:US
Practice Address - Phone:212-344-5361
Practice Address - Fax:212-514-5460
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1673501207Q00000X
NY167350204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A64582Medicare UPIN
BW032E5310Medicare ID - Type Unspecified