Provider Demographics
NPI:1568657005
Name:WALDEN MEDICAL, PLLC
Entity Type:Organization
Organization Name:WALDEN MEDICAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FRANKLIN
Authorized Official - Middle Name:P
Authorized Official - Last Name:GUNERATNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:845-778-5811
Mailing Address - Street 1:142 SOUTH MONTGOMERY ST
Mailing Address - Street 2:
Mailing Address - City:WALDEN
Mailing Address - State:NY
Mailing Address - Zip Code:12586
Mailing Address - Country:US
Mailing Address - Phone:845-778-5811
Mailing Address - Fax:845-778-5564
Practice Address - Street 1:142 SOUTH MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:WALDEN
Practice Address - State:NY
Practice Address - Zip Code:12586
Practice Address - Country:US
Practice Address - Phone:845-778-5811
Practice Address - Fax:845-778-5564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-07
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY117499207R00000X
NY007210363A00000X
NY304569363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00373744Medicaid
NYB17318Medicare UPIN