Provider Demographics
NPI:1952477507
Name:WALD, ROBERT M JR (MD INC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:M
Last Name:WALD
Suffix:JR
Gender:M
Credentials:MD INC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:100 E. VALENCIA MESA DRIVE
Mailing Address - Street 2:#300
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835
Mailing Address - Country:US
Mailing Address - Phone:714-738-4282
Mailing Address - Fax:714-738-1862
Practice Address - Street 1:100 E. VALENCIA MESA DRIVE
Practice Address - Street 2:#300
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835
Practice Address - Country:US
Practice Address - Phone:714-738-4282
Practice Address - Fax:714-738-1862
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG39788208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery