Provider Demographics
NPI:1386364719
Name:WALDEN, EDWARD SR
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:
Last Name:WALDEN
Suffix:SR
Gender:M
Credentials:
Other - Prefix:PROF
Other - First Name:EDWARD
Other - Middle Name:
Other - Last Name:WALDEN
Other - Suffix:SR
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:2502 W 23RD ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209-3402
Mailing Address - Country:US
Mailing Address - Phone:904-316-1740
Mailing Address - Fax:
Practice Address - Street 1:2502 W 23RD ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-3402
Practice Address - Country:US
Practice Address - Phone:904-316-1740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL435220542130172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver