Provider Demographics
NPI:1437265774
Name:WALDBAUM, BASIL S (MD)
Entity Type:Individual
Prefix:
First Name:BASIL
Middle Name:S
Last Name:WALDBAUM
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 1:8300 TYLER BLVD.
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-4328
Mailing Address - Country:US
Mailing Address - Phone:440-205-1529
Mailing Address - Fax:440-205-1529
Practice Address - Street 1:8300 TYLER BLVD.
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-4328
Practice Address - Country:US
Practice Address - Phone:440-205-1529
Practice Address - Fax:440-205-1529
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAW3083893207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0390090Medicaid
WA4177841Medicare ID - Type Unspecified
OH0390090Medicaid