Provider Demographics
NPI:1265635031
Name:DAN A. WADDELL, D.O., PLLC
Entity Type:Organization
Organization Name:DAN A. WADDELL, D.O., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:WADDELL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:817-267-0550
Mailing Address - Street 1:88 VILLAGE LN
Mailing Address - Street 2:SUITE 105
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-2972
Mailing Address - Country:US
Mailing Address - Phone:817-267-0550
Mailing Address - Fax:817-545-2368
Practice Address - Street 1:88 VILLAGE LN
Practice Address - Street 2:SUITE 105
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-2972
Practice Address - Country:US
Practice Address - Phone:817-267-0550
Practice Address - Fax:817-545-2368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-07
Last Update Date:2008-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD7703207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX191097801Medicaid
TX0028QHOtherBCBS
DN4715OtherMEDICARE RAILROAD
DN4715OtherMEDICARE RAILROAD