MEDICARE: DIANE WALDER MDPA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	ME74763	FL

General Provider Information

NPI Number	:	1023030038
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIANE WALDER MDPA

Provider Business Mailing Address
First Line	:	1111 KANE CONCOURSE
Second Line	:	SUITE 100
City	:	BAY HARBOR ISLANDS
State	:	FL
Zip	:	33154-2029
Country	:	US
Telephone Number	:	305-866-2177
Fax Number	:	305-866-5302

Provider Business Practice Location Address
First Line	:	1111 KANE CONCOURSE
Second Line	:	SUITE 100
City	:	BAY HARBOR ISLANDS
State	:	FL
Zip	:	33154-2029
Country	:	US
Telephone Number	:	305-866-2177
Fax Number	:	305-866-5302

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DIANE WALDER
Credential	:	MD
Telephone Number	:	305-866-2177

Provider Enumeration Date	:	07/25/2006
Last Update Date	:	08/22/2020

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