Provider Demographics
NPI:1679630446
Name:WALDREP, DONALD (MD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:
Last Name:WALDREP
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 1:110 JENSEN CT
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-7483
Mailing Address - Country:US
Mailing Address - Phone:805-230-0030
Mailing Address - Fax:805-230-2995
Practice Address - Street 1:110 JENSEN CT
Practice Address - Street 2:SUITE 1B
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-7483
Practice Address - Country:US
Practice Address - Phone:805-230-0030
Practice Address - Fax:805-230-2995
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG75982208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG52375Medicare UPIN
CA00G759820Medicare ID - Type UnspecifiedNORTHERN CALIFORNIA
CAW18243Medicare ID - Type UnspecifiedSOUTHERN CALIFORNIA