Provider Demographics
NPI:1194716688
Name:WALD, MARK S (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:WALD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11133 DUNN RD
Mailing Address - Street 2:SUITE 2335
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-6119
Mailing Address - Country:US
Mailing Address - Phone:314-653-5007
Mailing Address - Fax:
Practice Address - Street 1:6 JUNGERMANN CIR
Practice Address - Street 2:SUITE 210
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1621
Practice Address - Country:US
Practice Address - Phone:636-441-6056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8691207RP1001X, 207RS0012X
IL036081636207RP1001X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201751005Medicaid
MO290009909OtherRR MEDICARE PCI
MO29007538OtherRR MEDICARE PSC
ILK25143Medicare PIN
MO29007538OtherRR MEDICARE PSC
MO003010417Medicare PIN
ILK25144Medicare PIN
MO003010902Medicare PIN