Provider Demographics
NPI:1225104094
Name:RETAN, J WALDEN (MD)
Entity Type:Individual
Prefix:
First Name:J
Middle Name:WALDEN
Last Name:RETAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:W
Other - Last Name:RETAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:177 OAK RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:TALLADEGA
Mailing Address - State:AL
Mailing Address - Zip Code:35160-8303
Mailing Address - Country:US
Mailing Address - Phone:205-266-4928
Mailing Address - Fax:
Practice Address - Street 1:177 OAK RIDGE LN
Practice Address - Street 2:
Practice Address - City:TALLADEGA
Practice Address - State:AL
Practice Address - Zip Code:35160-8303
Practice Address - Country:US
Practice Address - Phone:205-266-4928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-25
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3223207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL5241Medicaid