Provider Demographics
NPI:1265629398
Name:WALDEN FAMILY MEDICINE, PA
Entity type:Organization
Organization Name:WALDEN FAMILY MEDICINE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACCI
Authorized Official - Middle Name:GAYLE
Authorized Official - Last Name:WALDEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:940-498-4445
Mailing Address - Street 1:3504 CORINTH PARKWAY
Mailing Address - Street 2:SUITE 150
Mailing Address - City:CORINTH
Mailing Address - State:TX
Mailing Address - Zip Code:76208
Mailing Address - Country:US
Mailing Address - Phone:940-498-4445
Mailing Address - Fax:940-270-5002
Practice Address - Street 1:3504 CORINTH PARKWAY
Practice Address - Street 2:SUITE 150
Practice Address - City:CORINTH
Practice Address - State:TX
Practice Address - Zip Code:76208
Practice Address - Country:US
Practice Address - Phone:940-498-4445
Practice Address - Fax:940-270-5002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-02
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL4162261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care