Provider Demographics
NPI:1013012897
Name:WASDAHL, DANIEL (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:WASDAHL
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 80690
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708
Mailing Address - Country:US
Mailing Address - Phone:330-833-5530
Mailing Address - Fax:330-833-6085
Practice Address - Street 1:2600 6TH ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44710
Practice Address - Country:US
Practice Address - Phone:330-438-6311
Practice Address - Fax:330-580-5546
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-065405207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0945884Medicaid
OH0945884Medicaid
WA0772291Medicare ID - Type Unspecified