Provider Demographics
NPI:1124019039
Name:WALD, DEBORAH JEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:DEBORAH
Middle Name:JEAN
Last Name:WALD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 9142
Mailing Address - Street 2:MASS GENERAL PHYSICIAN ORGANIZATION
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-724-0287
Mailing Address - Fax:617-726-2894
Practice Address - Street 1:300 OCEAN AVE
Practice Address - Street 2:RHC REVERE HEALTHCARE CENTER
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151-3675
Practice Address - Country:US
Practice Address - Phone:617-485-6350
Practice Address - Fax:617-485-6391
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA79608207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA724447OtherTUFTS HEALTH PLAN
MAJ31234OtherBCBS MA
MA3138968Medicaid
G04313Medicare UPIN
MAA20097Medicare ID - Type Unspecified