Healthcare Provider Details

I. General information

NPI: 1417585597
Provider Name (Legal Business Name): ZACHARY JON WALDER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2020
Last Update Date: 01/04/2024
Certification Date: 01/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4212 MISSOURI FLAT RD
PLACERVILLE CA
95667-6269
US

IV. Provider business mailing address

4212 MISSOURI FLAT RD
PLACERVILLE CA
95667-6269
US

V. Phone/Fax

Practice location:
  • Phone: 530-621-7700
  • Fax: 530-621-7713
Mailing address:
  • Phone: 530-621-7700
  • Fax: 530-621-7713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number20A21369
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: