=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184674822
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LON ANDREW WALDER D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2006
-----------------------------------------------------
Last Update Date | 09/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4018 EL INDIO HWY
-----------------------------------------------------
City | EAGLE PASS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78852-6690
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-872-3460
-----------------------------------------------------
Fax | 830-872-3470
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2525 N VETERANS BLVD
-----------------------------------------------------
City | EAGLE PASS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78852-3302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-773-8917
-----------------------------------------------------
Fax | 830-773-1892
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RI0011X
-----------------------------------------------------
Taxonomy Name | Interventional Cardiology Physician
-----------------------------------------------------
License Number | J3931
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | J3931
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------