Provider Demographics
NPI:1144239500
Name:WADDELL, DAVID J (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:WADDELL
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 1:751 SAPPINGTON BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:MO
Mailing Address - Zip Code:63080-2354
Mailing Address - Country:US
Mailing Address - Phone:573-468-4186
Mailing Address - Fax:
Practice Address - Street 1:751 SAPPINGTON BRIDGE RD
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:MO
Practice Address - Zip Code:63080-2354
Practice Address - Country:US
Practice Address - Phone:573-468-4186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023006560207R00000X, 208M00000X
IA31608207RG0300X
ARE9142208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0148593Medicaid
IA110149386OtherRR MEDICARE
MO208691204Medicaid
AR209747001Medicaid
IA421202636OtherTAX ID
AR419099YWUJOtherMEDICARE
IA421202636OtherTAX ID
AR209747001Medicaid