Provider Demographics
NPI:1437219698
Name:WALDT, GLENN J (DO)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:J
Last Name:WALDT
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:1180 COMMERCE DRIVE #14222
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-8255
Mailing Address - Country:US
Mailing Address - Phone:505-695-1227
Mailing Address - Fax:877-532-2113
Practice Address - Street 1:2900 HILLRISE DRIVE
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011
Practice Address - Country:US
Practice Address - Phone:505-695-1227
Practice Address - Fax:877-532-2113
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NMA045921204D00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM27552381Medicaid