Healthcare Provider Details

I. General information

NPI: 1285869362
Provider Name (Legal Business Name): NOAM A VANDERWALDE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2009
Last Update Date: 04/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7945 WOLF RIVER BLVD
GERMANTOWN TN
38138-1733
US

IV. Provider business mailing address

7714 POPLAR AVE STE 200 ATTN: CREDENTIALING
GERMANTOWN TN
38138-3941
US

V. Phone/Fax

Practice location:
  • Phone: 901-683-0055
  • Fax: 901-685-2969
Mailing address:
  • Phone: 901-322-9080
  • Fax: 901-922-6722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number51603
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number23666
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: