Provider Demographics
NPI:1689610602
Name:WALDBAUM, JEROME R (MD)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:R
Last Name:WALDBAUM
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 1:4225 HOYT AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98203-2351
Mailing Address - Country:US
Mailing Address - Phone:425-259-3122
Mailing Address - Fax:
Practice Address - Street 1:4225 HOYT AVE
Practice Address - Street 2:SUITE A
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-2351
Practice Address - Country:US
Practice Address - Phone:425-259-3122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2008-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00020538207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0037731OtherLABOR AND INDUSTRY
WAMD00020538OtherSTATE LICENSE NUMBER
WA8483505Medicaid
WA8483505Medicaid