Healthcare Provider Details

I. General information

NPI: 1790881043
Provider Name (Legal Business Name): MARC DAVID WALDMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 12/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

892 ROUTE 35
CROSS RIVER NY
10518-1141
US

IV. Provider business mailing address

P.O. BOX 612
CROSS RIVER NY
10518-0612
US

V. Phone/Fax

Practice location:
  • Phone: 914-763-6119
  • Fax:
Mailing address:
  • Phone: 914-763-6119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number183880
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: