Healthcare Provider Details

I. General information

NPI: 1225617483
Provider Name (Legal Business Name): NICOLAS ALLEN WALDECKER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2021
Last Update Date: 06/04/2025
Certification Date: 06/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 ROBINSON ST
BINGHAMTON NY
13904
US

IV. Provider business mailing address

719 HARRISON ST
SYRACUSE NY
13210-2695
US

V. Phone/Fax

Practice location:
  • Phone: 607-724-1391
  • Fax: 607-773-4387
Mailing address:
  • Phone: 315-464-3265
  • Fax: 315-464-3282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number334248
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: