Provider Demographics
NPI:1689752123
Name:CHARLES, WALDECK (MD)
Entity Type:Individual
Prefix:
First Name:WALDECK
Middle Name:
Last Name:CHARLES
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 1:1400 N GILBERT RD
Mailing Address - Street 2:SUITE H
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2328
Mailing Address - Country:US
Mailing Address - Phone:602-315-7033
Mailing Address - Fax:480-813-4534
Practice Address - Street 1:1400 N GILBERT RD
Practice Address - Street 2:SUITE H
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2328
Practice Address - Country:US
Practice Address - Phone:602-315-7033
Practice Address - Fax:480-813-4534
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2012-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ335212084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ915366Medicaid
AZ102444Medicare ID - Type Unspecified
AZ915366Medicaid