Healthcare Provider Details

I. General information

NPI: 1760446637
Provider Name (Legal Business Name): JAMES M WALDECK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 12/30/2021
Certification Date: 12/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 MEDICAL CENTER DR STE 3500
HUNTINGTON WV
25701-3655
US

IV. Provider business mailing address

1600 MEDICAL CENTER DR SUITE 3500
HUNTINGTON WV
25701-3656
US

V. Phone/Fax

Practice location:
  • Phone: 304-691-1300
  • Fax: 304-691-1375
Mailing address:
  • Phone: 304-691-1300
  • Fax: 304-691-1375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number14006
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: