Healthcare Provider Details

I. General information

NPI: 1548228893
Provider Name (Legal Business Name): JAMIE M WALDREP MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 08/01/2022
Certification Date: 08/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 STRICKLAND DR
ORANGE TX
77630-4750
US

IV. Provider business mailing address

250 STRICKLAND DR
ORANGE TX
77630-4750
US

V. Phone/Fax

Practice location:
  • Phone: 409-883-7900
  • Fax: 409-883-7909
Mailing address:
  • Phone: 409-883-7900
  • Fax: 409-883-7909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberM3107
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JAMIE M WALDREP
Title or Position: OWNER
Credential: MD
Phone: 409-883-7900