Provider Demographics
NPI:1346770427
Name:WALDNER, DERICK (DO)
Entity type:Individual
Prefix:
First Name:DERICK
Middle Name:
Last Name:WALDNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E OLNEY AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19120-2470
Mailing Address - Country:US
Mailing Address - Phone:215-456-1825
Mailing Address - Fax:215-456-5926
Practice Address - Street 1:559 W GERMANTOWN PIKE
Practice Address - Street 2:
Practice Address - City:NORRISTOWN
Practice Address - State:PA
Practice Address - Zip Code:19403-4250
Practice Address - Country:US
Practice Address - Phone:484-622-1248
Practice Address - Fax:484-622-1269
Is Sole Proprietor?:No
Enumeration Date:2017-06-12
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB11374600207L00000X
NJ390200000X
PAOS021822207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program