Healthcare Provider Details

I. General information

NPI: 1376736330
Provider Name (Legal Business Name): WALDMAN PLASTIC SURGERY AND DERMATOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2007
Last Update Date: 08/12/2021
Certification Date: 08/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 RIVERSIDE ST STE 105
NASHUA NH
03062-1383
US

IV. Provider business mailing address

17 RIVERSIDE ST STE 105
NASHUA NH
03062-1383
US

V. Phone/Fax

Practice location:
  • Phone: 603-577-5559
  • Fax: 603-577-5579
Mailing address:
  • Phone: 603-577-5559
  • Fax: 603-577-5579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number13474
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number13475
License Number StateNH

VIII. Authorized Official

Name: JEREMY WALDMAN
Title or Position: OWNER/MEDICAL DOCTOR
Credential: M.D.
Phone: 603-577-5559