Provider Demographics
NPI:1710237037
Name:WALDORF PEDIATRICS
Entity Type:Organization
Organization Name:WALDORF PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CANDICE
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:BOSWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-645-1781
Mailing Address - Street 1:4255 ALTAMONT PL
Mailing Address - Street 2:#301
Mailing Address - City:WHITE PLAINS
Mailing Address - State:MD
Mailing Address - Zip Code:20695
Mailing Address - Country:US
Mailing Address - Phone:301-645-1781
Mailing Address - Fax:301-374-9237
Practice Address - Street 1:4255 ALTAMONT PLACE
Practice Address - Street 2:SUITE 301
Practice Address - City:WHITE PLAINS
Practice Address - State:MD
Practice Address - Zip Code:20695
Practice Address - Country:US
Practice Address - Phone:301-645-1781
Practice Address - Fax:301-374-9237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-13
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0064240208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDH96241Medicaid