Provider Demographics
NPI:1982684932
Name:WALDREP, NATHAN KEITH (MD)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:KEITH
Last Name:WALDREP
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 1:6827 1ST AVE S
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33707-1242
Mailing Address - Country:US
Mailing Address - Phone:727-767-0575
Mailing Address - Fax:727-333-6020
Practice Address - Street 1:13670 WALSINGHAM RD
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33774-3532
Practice Address - Country:US
Practice Address - Phone:727-593-9848
Practice Address - Fax:727-596-4532
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME58834207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010786600Medicaid
FLP01350523OtherMEDICARE RAILROAD PROVIDER NUMBER
FL010786600Medicaid
FLP01350523OtherMEDICARE RAILROAD PROVIDER NUMBER
FL11495VMedicare PIN
FLE66213Medicare UPIN