Provider Demographics
NPI:1992201883
Name:WOLDT, ALEX
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:
Last Name:WOLDT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 HIGHLANDS DR
Mailing Address - Street 2:
Mailing Address - City:LITITZ
Mailing Address - State:PA
Mailing Address - Zip Code:17543-7694
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 MULLINS DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-3983
Practice Address - Country:US
Practice Address - Phone:541-259-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-01
Last Update Date:2020-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
146L00000X, 390200000X
PAOT020297207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program