Provider Demographics
NPI:1437100062
Name:WADDELL, DAN A (DO)
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:A
Last Name:WADDELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1721 CIMARRON TRL
Mailing Address - Street 2:SUITE 5
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76054-3400
Mailing Address - Country:US
Mailing Address - Phone:817-267-0550
Mailing Address - Fax:817-545-2368
Practice Address - Street 1:1721 CIMARRON TRL
Practice Address - Street 2:SUITE 5
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76054-3400
Practice Address - Country:US
Practice Address - Phone:817-267-0550
Practice Address - Fax:817-545-2368
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2015-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD7703207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8AQ470OtherBCBS
TX127778202Medicaid
TX127778206Medicaid
P00621292OtherMEDICARE RAILROAD
TX00D525OtherBCBS NUMBER
113928802OtherMEDICARE RAILROAD
TX8AQ470OtherBCBS
TX127778206Medicaid
TX8F6084Medicare PIN