Provider Demographics
NPI:1962486464
Name:WALDRON, RICHARD JOHN (PT)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:JOHN
Last Name:WALDRON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:RICH
Other - Middle Name:
Other - Last Name:WALDRON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:257 ETHEL AVE
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-2731
Mailing Address - Country:US
Mailing Address - Phone:415-302-0456
Mailing Address - Fax:
Practice Address - Street 1:1099 D STREET SUITE 105
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2839
Practice Address - Country:US
Practice Address - Phone:415-532-8395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT15104225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFY242AMedicare PIN