Provider Demographics
NPI:1831213248
Name:WALDEN, MARK ELLIOTT (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ELLIOTT
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 1:190 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:RATON
Mailing Address - State:NM
Mailing Address - Zip Code:87740-2002
Mailing Address - Country:US
Mailing Address - Phone:575-445-5563
Mailing Address - Fax:575-445-5566
Practice Address - Street 1:190 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:RATON
Practice Address - State:NM
Practice Address - Zip Code:87740
Practice Address - Country:US
Practice Address - Phone:575-445-5563
Practice Address - Fax:575-445-5566
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0044433208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice