Provider Demographics
NPI:1659471845
Name:WALDMAN, JUSTINE L (MD)
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:L
Last Name:WALDMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 DATES DR
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1342
Mailing Address - Country:US
Mailing Address - Phone:607-274-4150
Mailing Address - Fax:607-274-4132
Practice Address - Street 1:101 DATES DR
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1342
Practice Address - Country:US
Practice Address - Phone:607-274-4150
Practice Address - Fax:607-274-4132
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225677207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
00220092OtherABEM
NY02298626Medicaid
CAA70878OtherSTATE LICENSE
NY225677OtherSTATE LICENSE
NY225677OtherSTATE LICENSE
NYRB8125Medicare PIN
NYBW6746311OtherDEA
CAA70878OtherSTATE LICENSE
NYJ400039384Medicare PIN