Provider Demographics
NPI:1982716486
Name:WALDO, BRYAN (MD)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:WALDO
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 W 22ND ST STE 200
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1563
Mailing Address - Country:US
Mailing Address - Phone:630-575-5000
Mailing Address - Fax:
Practice Address - Street 1:2711 LEONARD DR STE 101
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-7121
Practice Address - Country:US
Practice Address - Phone:219-462-6001
Practice Address - Fax:219-464-6060
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01064566A207RN0300X, 207R00000X, 207RN0300X
IL036113432207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200889490Medicaid
ILI47191Medicare UPIN
ILK23487Medicare ID - Type Unspecified
IN164210Medicare PIN