Provider Demographics
NPI:1962511733
Name:WALD, JONATHAN DANIEL (LAC, AP)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:DANIEL
Last Name:WALD
Suffix:
Gender:M
Credentials:LAC, AP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3850 S OSPREY AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-6829
Mailing Address - Country:US
Mailing Address - Phone:941-320-1719
Mailing Address - Fax:
Practice Address - Street 1:3850 S OSPREY AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-6829
Practice Address - Country:US
Practice Address - Phone:941-320-1719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC00002134171100000X
FLAP2534171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist