Provider Demographics
NPI:1245217769
Name:SODERDAHL, DOUGLAS WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:WAYNE
Last Name:SODERDAHL
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 1:3851 ROGER BROOKE DRIVE
Mailing Address - Street 2:MCHE-QD
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-6200
Mailing Address - Country:US
Mailing Address - Phone:210-916-2460
Mailing Address - Fax:
Practice Address - Street 1:3851 ROGER BROOKE DRIVE
Practice Address - Street 2:MCHE-QD
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-6200
Practice Address - Country:US
Practice Address - Phone:210-916-2460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101233888171000000X
WI34673-20208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No171000000XOther Service ProvidersMilitary Health Care Provider