Provider Demographics
NPI:1871592840
Name:WALDHOLTZ, BRUCE (MD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:
Last Name:WALDHOLTZ
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 1:113 GAINSBOROUGH SQ STE 101
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-1713
Mailing Address - Country:US
Mailing Address - Phone:757-436-3285
Mailing Address - Fax:757-432-2262
Practice Address - Street 1:113 GAINSBOROUGH SQ STE 202
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-1714
Practice Address - Country:US
Practice Address - Phone:757-436-3285
Practice Address - Fax:757-436-2262
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101042167207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
325204OtherANTHEM
P00022692OtherRAILROAD MEDICARE
VA5821088Medicaid
15925OtherSENTARA
325201OtherANTHEM
VA5821088Medicaid
P00022692OtherRAILROAD MEDICARE