Provider Demographics
NPI:1295541878
Name:WALDMAN, KYLE JAMES
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:JAMES
Last Name:WALDMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5119 PRAIRIE GOURD MDW
Mailing Address - Street 2:
Mailing Address - City:MANVEL
Mailing Address - State:TX
Mailing Address - Zip Code:77578-4072
Mailing Address - Country:US
Mailing Address - Phone:585-721-9934
Mailing Address - Fax:
Practice Address - Street 1:5119 PRAIRIE GOURD MDW
Practice Address - Street 2:
Practice Address - City:MANVEL
Practice Address - State:TX
Practice Address - Zip Code:77578-4072
Practice Address - Country:US
Practice Address - Phone:585-721-9934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1402811225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist