Provider Demographics
NPI:1265600787
Name:WALDO, GUY BRUCE (MD)
Entity type:Individual
Prefix:DR
First Name:GUY
Middle Name:BRUCE
Last Name:WALDO
Suffix:
Gender:M
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:PO BOX 4777
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47402-4777
Mailing Address - Country:US
Mailing Address - Phone:812-336-1690
Mailing Address - Fax:
Practice Address - Street 1:5521 W LINCOLN HWY
Practice Address - Street 2:STE 1A
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-1097
Practice Address - Country:US
Practice Address - Phone:219-769-8284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-19
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01031941A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine