Healthcare Provider Details

I. General information

NPI: 1275627366
Provider Name (Legal Business Name): JOHN JOSEPH WALD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 04/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 E MICHIGAN AVE STE 230
JACKSON MI
49201-1852
US

IV. Provider business mailing address

PO BOX 67000 DEPARTMENT 272801
DETROIT MI
48267-2728
US

V. Phone/Fax

Practice location:
  • Phone: 517-817-7620
  • Fax: 517-817-7619
Mailing address:
  • Phone: 517-817-7620
  • Fax: 517-817-7619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number4301052794
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: