Provider Demographics
NPI:1427168913
Name:WALDEN, JERRY SAMUEL (MD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:SAMUEL
Last Name:WALDEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3174 PACKARD ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1947
Mailing Address - Country:US
Mailing Address - Phone:734-971-1073
Mailing Address - Fax:734-971-8545
Practice Address - Street 1:3174 PACKARD ST
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-1947
Practice Address - Country:US
Practice Address - Phone:734-971-1073
Practice Address - Fax:734-971-8545
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIJW027573207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0817265OtherBLUE CARE NETWORK
MI103791OtherCARE CHOICES
MIC-2855OtherM-CARE
MIB45555OtherHAP
MI0808172651OtherBCBS
MI1639933Medicaid
MIC-2855OtherM-CARE
MI103791OtherCARE CHOICES