www.marshallortho.com

Douglas A. Waldman, MD

 TEXAS LICENSE E6674 / UPIN B61753

NPI 1902801871 / TPI 158777601

304 University, Suite 212      Marshall, Texas 75670-5247

Phone [903] 935-1151 -- Fax [903] 935-0077

DME PRESCRIPTION

 

Patient Name:

Item  : 

               

               

               

Dispense : 

Diagnosis: 

                   

Length of need :

This equipment is medically necessary.

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     ___ Douglas A. Waldman, MD

Date: