Healthcare Provider Details

I. General information

NPI: 1710237037
Provider Name (Legal Business Name): WALDORF PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2012
Last Update Date: 12/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4255 ALTAMONT PLACE SUITE 301
WHITE PLAINS MD
20695
US

IV. Provider business mailing address

4255 ALTAMONT PL #301
WHITE PLAINS MD
20695
US

V. Phone/Fax

Practice location:
  • Phone: 301-645-1781
  • Fax: 301-374-9237
Mailing address:
  • Phone: 301-645-1781
  • Fax: 301-374-9237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0064240
License Number StateMD

VIII. Authorized Official

Name: CANDICE MICHELLE BOSWELL
Title or Position: OFFICE MANAGER
Credential:
Phone: 301-645-1781