Provider Demographics
NPI:1487615795
Name:WALDMAN, GARY DAVID (MD)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:DAVID
Last Name:WALDMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:10512 PARK RD
Mailing Address - Street 2:SUITE 113
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-8469
Mailing Address - Country:US
Mailing Address - Phone:704-542-8018
Mailing Address - Fax:704-542-7147
Practice Address - Street 1:10512 PARK RD
Practice Address - Street 2:SUITE 113
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-8469
Practice Address - Country:US
Practice Address - Phone:704-542-8018
Practice Address - Fax:704-542-7147
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-29
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC26610207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7985246Medicaid
NC070009176OtherRAILROAD MEDICARE
NC85246OtherBLUE CROSS BLUE SHIELD
C81468Medicare UPIN
NC7985246Medicaid