Healthcare Provider Details

I. General information

NPI: 1386709947
Provider Name (Legal Business Name): GREG ROSS WALDORF O.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 OLD RIVER RD STE 201
LINCOLN RI
02865-1158
US

IV. Provider business mailing address

99 E MAIN RD
MIDDLETOWN RI
02842-4983
US

V. Phone/Fax

Practice location:
  • Phone: 401-721-5599
  • Fax: 401-721-5597
Mailing address:
  • Phone: 401-848-7400
  • Fax: 401-848-7402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODTGA00591
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: