Provider Demographics
NPI:1245216845
Name:WADESON, DOUGLAS A (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:A
Last Name:WADESON
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 1:212 S SALEM ST
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27502-1825
Mailing Address - Country:US
Mailing Address - Phone:919-362-5201
Mailing Address - Fax:919-387-5905
Practice Address - Street 1:212 S SALEM ST
Practice Address - Street 2:
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502-1825
Practice Address - Country:US
Practice Address - Phone:919-362-5201
Practice Address - Fax:919-387-5905
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2014-00247207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL377344200Medicaid
FL080075531OtherRR MEDICARE
F89933Medicare UPIN
FL25812ZMedicare PIN