Healthcare Provider Details

I. General information

NPI: 1437219698
Provider Name (Legal Business Name): GLENN J WALDT DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 05/08/2024
Certification Date: 05/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2803 DORAL CT
LAS CRUCES NM
88011-8616
US

IV. Provider business mailing address

1180 COMMERCE DRIVE #14222
LAS CRUCES NM
88011-8255
US

V. Phone/Fax

Practice location:
  • Phone: 46-984-4063
  • Fax: 877-532-2113
Mailing address:
  • Phone: 505-695-1227
  • Fax: 877-532-2113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License NumberA045921
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: