Provider Demographics
NPI:1134125065
Name:WALDINGER, THOMAS POWELL (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:POWELL
Last Name:WALDINGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 N LILLEY RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-3907
Mailing Address - Country:US
Mailing Address - Phone:734-495-1506
Mailing Address - Fax:734-829-2589
Practice Address - Street 1:285 N LILLEY RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-3907
Practice Address - Country:US
Practice Address - Phone:734-495-1506
Practice Address - Fax:734-829-2589
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301043778207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P12450OtherMEDICARE GROUP
MI0P12450OtherMEDICARE GROUP
MIP1245001Medicare PIN