Provider Demographics
NPI:1801983614
Name:WALDEN, ARCHIE DON (MD)
Entity type:Individual
Prefix:
First Name:ARCHIE
Middle Name:DON
Last Name:WALDEN
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 1:2700 HWY 34 EAST BLDG 300
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265
Mailing Address - Country:US
Mailing Address - Phone:770-304-0987
Mailing Address - Fax:770-304-0428
Practice Address - Street 1:2700 HWY 34 EAST BLDG 300
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265
Practice Address - Country:US
Practice Address - Phone:770-304-0987
Practice Address - Fax:770-304-0428
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA041381207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000718902EMedicaid
GA000718902EMedicaid
GA202I088270Medicare Oscar/Certification