Provider Demographics
NPI:1912994807
Name:WALDECK, EDWARD W (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:W
Last Name:WALDECK
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 1:6020 S PACKARD AVE
Mailing Address - Street 2:
Mailing Address - City:CUDAHY
Mailing Address - State:WI
Mailing Address - Zip Code:53110-3028
Mailing Address - Country:US
Mailing Address - Phone:414-294-4660
Mailing Address - Fax:414-294-4396
Practice Address - Street 1:6020 S PACKARD AVE
Practice Address - Street 2:
Practice Address - City:CUDAHY
Practice Address - State:WI
Practice Address - Zip Code:53110-3028
Practice Address - Country:US
Practice Address - Phone:414-294-4660
Practice Address - Fax:414-294-4396
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16654-020207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39-1484998EOtherHUMANA
WI391484998011OtherBC/CC
WI391484998OtherTAX ID
WI180021822OtherRR MEDICARE
WI0800048OtherPRIMECARE
WI30936100Medicaid
0565030004Medicare NSC
0565030001Medicare NSC
WI391484998OtherTAX ID
0565030003Medicare NSC
WI180021822OtherRR MEDICARE
WIB57422Medicare UPIN