Provider Demographics
NPI:1467741348
Name:WAIDO, JACLYN NIDERSTADT (MD)
Entity Type:Individual
Prefix:DR
First Name:JACLYN
Middle Name:NIDERSTADT
Last Name:WAIDO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JACLYN
Other - Middle Name:A
Other - Last Name:NIEDERSTADT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:10350 E DAKOTA AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80247-1314
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1375 E 20TH AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80205-5422
Practice Address - Country:US
Practice Address - Phone:303-338-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-31
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0053985208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO74720384Medicaid
CO024947OtherKAISER COMMERCIAL NUMBER
CO378409YK5YMedicare PIN