Healthcare Provider Details

I. General information

NPI: 1093785651
Provider Name (Legal Business Name): BRIAN J WALDRON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 01/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 BROADWAY STE 910
NEW YORK NY
10006-2736
US

IV. Provider business mailing address

61 BROADWAY STE 910
NEW YORK NY
10006-2736
US

V. Phone/Fax

Practice location:
  • Phone: 212-344-5361
  • Fax: 212-514-5460
Mailing address:
  • Phone: 212-344-5361
  • Fax: 212-514-5460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1673501
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number167350
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: