Provider Demographics
NPI:1205582269
Name:WALDRON, SAMUEL ROBERT (DPT)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:ROBERT
Last Name:WALDRON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 ATTENBOROUGH DR APT 304
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:MD
Mailing Address - Zip Code:21237-5728
Mailing Address - Country:US
Mailing Address - Phone:201-783-6687
Mailing Address - Fax:
Practice Address - Street 1:3100 BOSTON STREET
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224
Practice Address - Country:US
Practice Address - Phone:410-995-9055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-28
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA02074900225100000X
MD29384225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist