Healthcare Provider Details

I. General information

NPI: 1568657005
Provider Name (Legal Business Name): WALDEN MEDICAL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2007
Last Update Date: 09/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142 SOUTH MONTGOMERY ST
WALDEN NY
12586
US

IV. Provider business mailing address

142 SOUTH MONTGOMERY ST
WALDEN NY
12586
US

V. Phone/Fax

Practice location:
  • Phone: 845-778-5811
  • Fax: 845-778-5564
Mailing address:
  • Phone: 845-778-5811
  • Fax: 845-778-5564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number117499
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number007210
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number304569
License Number StateNY

VIII. Authorized Official

Name: FRANKLIN P GUNERATNE
Title or Position: OWNER
Credential: M.D.
Phone: 845-778-5811