Provider Demographics
NPI:1558305540
Name:WAMBOLDT, ALAN DALE (MD)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:DALE
Last Name:WAMBOLDT
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 1:7525 E BROADWAY RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85208-2002
Mailing Address - Country:US
Mailing Address - Phone:480-832-2097
Mailing Address - Fax:480-832-0530
Practice Address - Street 1:7525 E BROADWAY RD
Practice Address - Street 2:SUITE 3
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85208-2002
Practice Address - Country:US
Practice Address - Phone:480-832-2097
Practice Address - Fax:480-832-0530
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ17046174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD00531Medicare UPIN
AZ103002Medicare ID - Type Unspecified