Provider Demographics
NPI:1134236524
Name:WALDMAN, RANDOLPH WILLIAM (MD PC)
Entity type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:WILLIAM
Last Name:WALDMAN
Suffix:
Gender:M
Credentials:MD PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:HEBRON
Mailing Address - State:NE
Mailing Address - Zip Code:68370-2019
Mailing Address - Country:US
Mailing Address - Phone:402-768-7203
Mailing Address - Fax:402-768-4697
Practice Address - Street 1:120 PARK AVE
Practice Address - Street 2:
Practice Address - City:HEBRON
Practice Address - State:NE
Practice Address - Zip Code:68370-2019
Practice Address - Country:US
Practice Address - Phone:402-768-7203
Practice Address - Fax:402-768-4697
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE27738207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE000000OtherAFFILIATED WITH THAYER MEMORIAL HOSPITAL
COC23055Medicare UPIN
CO77389573Medicaid
CO802333OtherMEMORIAL HOSPITAL AFFLIIATED PIN/PTAN