Provider Demographics
NPI:1205859535
Name:WALD, DAVID A (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:WALD
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 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-367-4030
Mailing Address - Fax:208-367-4051
Practice Address - Street 1:1055 N CURTIS ROAD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706
Practice Address - Country:US
Practice Address - Phone:208-367-4030
Practice Address - Fax:208-367-4051
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 83180208100000X
IDM-14009208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL264726500Medicaid
FL06129YMedicare PIN