MEDICARE: DIANE WALDER M.D.

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	ME39412	FL

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	:	1588697221
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANE WALDER M.D.

Provider Business Mailing Address
First Line	:	15051 S TAMIAMI TRL STE 203
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33908-5182
Country	:	US
Telephone Number	:	239-437-8810
Fax Number	:	239-313-2555

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	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2006
Last Update Date	:	01/11/2018

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Directions to “ DIANE WALDER M.D.” Practice Location

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