Provider Demographics
NPI:1356501514
Name:WALDO, ERIC WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:WILLIAM
Last Name:WALDO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1205 PROVIDENT DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-3265
Practice Address - Country:US
Practice Address - Phone:574-269-8383
Practice Address - Fax:574-269-8384
Is Sole Proprietor?:No
Enumeration Date:2008-06-11
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01067105A207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200968810Medicaid
INM400047688Medicare PIN