Provider Demographics
NPI:1275627366
Name:WALD, JOHN JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:JOSEPH
Last Name:WALD
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 67000
Mailing Address - Street 2:DEPARTMENT 272801
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-2728
Mailing Address - Country:US
Mailing Address - Phone:517-817-7620
Mailing Address - Fax:517-817-7619
Practice Address - Street 1:1201 E MICHIGAN AVE
Practice Address - Street 2:STE 230
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1852
Practice Address - Country:US
Practice Address - Phone:517-817-7620
Practice Address - Fax:517-817-7619
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2011-04-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI43010527942084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4256604Medicaid
MIF42075Medicare UPIN
MI0P01670Medicare ID - Type Unspecified