MEDICARE: MR. DOUGLAS RAY WALDING III

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	163WC0200X	Critical Care Medicine Registered Nurse	212145	LA

General Provider Information

NPI Number	:	1669200838
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DOUGLAS RAY WALDING III

Provider Business Mailing Address
First Line	:	26694 MITCHELL LN
Second Line	:
City	:	LIVINGSTON
State	:	LA
Zip	:	70754-3002
Country	:	US
Telephone Number	:	225-788-8301
Fax Number	:

Provider Business Practice Location Address
First Line	:	26694 MITCHELL LN
Second Line	:
City	:	LIVINGSTON
State	:	LA
Zip	:	70754-3002
Country	:	US
Telephone Number	:	225-788-8301
Fax Number	:

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

Provider Enumeration Date	:	07/22/2024
Last Update Date	:	07/22/2024

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