Healthcare Provider Details

I. General information

NPI: 1134125065
Provider Name (Legal Business Name): THOMAS POWELL WALDINGER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 10/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 N LILLEY RD
CANTON MI
48187-3907
US

IV. Provider business mailing address

285 N LILLEY RD
CANTON MI
48187-3907
US

V. Phone/Fax

Practice location:
  • Phone: 734-495-1506
  • Fax: 734-829-2589
Mailing address:
  • Phone: 734-495-1506
  • Fax: 734-829-2589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number4301043778
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number4301043778
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: