Provider Demographics
NPI:1851488464
Name:WALDRON, JEANNETTE WAGNER (MD)
Entity Type:Individual
Prefix:
First Name:JEANNETTE
Middle Name:WAGNER
Last Name:WALDRON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JEANNETTE
Other - Middle Name:MARIE
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:126 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:MT
Mailing Address - Zip Code:59047
Mailing Address - Country:US
Mailing Address - Phone:406-222-1111
Mailing Address - Fax:
Practice Address - Street 1:126 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:MT
Practice Address - Zip Code:59047
Practice Address - Country:US
Practice Address - Phone:406-222-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT10855207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine