Provider Demographics
NPI:1033445218
Name:WADDELL, ROBERT DONALD III (DC)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:DONALD
Last Name:WADDELL
Suffix:III
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12099 LINDSTROM LN
Mailing Address - Street 2:
Mailing Address - City:LINDSTROM
Mailing Address - State:MN
Mailing Address - Zip Code:55045-9543
Mailing Address - Country:US
Mailing Address - Phone:651-257-1103
Mailing Address - Fax:651-257-1552
Practice Address - Street 1:12099 LAKE BLVD
Practice Address - Street 2:
Practice Address - City:LINDSTROM
Practice Address - State:MN
Practice Address - Zip Code:55045-9322
Practice Address - Country:US
Practice Address - Phone:651-257-1103
Practice Address - Fax:651-257-1552
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-23
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5301111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor