Healthcare Provider Details

I. General information

NPI: 1265895692
Provider Name (Legal Business Name): DOUGLAS WALD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2016
Last Update Date: 04/16/2023
Certification Date: 04/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6358 SPRINGFIELD PLZ
SPRINGFIELD VA
22150-3431
US

IV. Provider business mailing address

1 HOLLOW LN STE 301
NEW HYDE PARK NY
11042-1215
US

V. Phone/Fax

Practice location:
  • Phone: 703-644-5437
  • Fax:
Mailing address:
  • Phone: 516-207-7851
  • Fax: 914-259-5499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0096941
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101268482
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: