Provider Demographics
NPI:1487689329
Name:WALDMAN, ROBERT PHLIP (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:PHLIP
Last Name:WALDMAN
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 1:4644 LINCOLN BLVD STE 540
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6391
Mailing Address - Country:US
Mailing Address - Phone:310-301-0015
Mailing Address - Fax:310-301-4882
Practice Address - Street 1:4644 LINCOLN BLVD STE 540
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6391
Practice Address - Country:US
Practice Address - Phone:310-301-0015
Practice Address - Fax:310-301-4882
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG49826174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G498260Medicaid
CA00G498260Medicaid
CAG49826Medicare ID - Type Unspecified