Provider Demographics
NPI:1588022453
Name:WALD, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WALD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 SMITH AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT KISCO
Mailing Address - State:NY
Mailing Address - Zip Code:10549-2816
Mailing Address - Country:US
Mailing Address - Phone:914-242-8844
Mailing Address - Fax:
Practice Address - Street 1:86 SMITH AVE
Practice Address - Street 2:
Practice Address - City:MOUNT KISCO
Practice Address - State:NY
Practice Address - Zip Code:10549-2816
Practice Address - Country:US
Practice Address - Phone:914-242-8844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-05
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX006632111N00000X
NY005391133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered