Provider Demographics
NPI:1184674822
Name:WALDER, LON ANDREW (DO)
Entity type:Individual
Prefix:
First Name:LON
Middle Name:ANDREW
Last Name:WALDER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 N VETERANS BLVD
Mailing Address - Street 2:
Mailing Address - City:EAGLE PASS
Mailing Address - State:TX
Mailing Address - Zip Code:78852-3302
Mailing Address - Country:US
Mailing Address - Phone:830-773-8917
Mailing Address - Fax:830-773-1892
Practice Address - Street 1:4018 EL INDIO HWY
Practice Address - Street 2:
Practice Address - City:EAGLE PASS
Practice Address - State:TX
Practice Address - Zip Code:78852-6690
Practice Address - Country:US
Practice Address - Phone:830-872-3460
Practice Address - Fax:830-872-3470
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3931207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1360869-02Medicaid
TX4376993OtherAETNA PROVIDER ID
TX136086909Medicaid
TX1360869-05Medicaid
TX1360869-11Medicaid
TX86462KOtherBCBS
TX4376993OtherAETNA PROVIDER ID
TX8L13692Medicare PIN
TX060051196Medicare PIN
TX1360869-05Medicaid
TX136086909Medicaid