MEDICARE: DR. GLENN J WALDT DO

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	204D00000X	Neuromusculoskeletal Medicine & OMM Physician	A045921	NM
2	390200000X	Student in an Organized Health Care Education/Training Program

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1437219698
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GLENN J WALDT DO

Provider Business Mailing Address
First Line	:	1180 COMMERCE DRIVE #14222
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-8255
Country	:	US
Telephone Number	:	505-695-1227
Fax Number	:	877-532-2113

Provider Business Practice Location Address
First Line	:	2803 DORAL CT
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-8616
Country	:	US
Telephone Number	:	46-984-4063
Fax Number	:	877-532-2113

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/11/2006
Last Update Date	:	05/08/2024

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