Provider Demographics
NPI:1467689265
Name:WADDELL, BRADFORD S (MD)
Entity Type:Individual
Prefix:
First Name:BRADFORD
Middle Name:S
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 1:9301 N CENTRAL EXPY STE 500
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-0805
Mailing Address - Country:US
Mailing Address - Phone:214-220-2468
Mailing Address - Fax:214-378-3325
Practice Address - Street 1:9301 N CENTRAL EXPY STE 500
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-0805
Practice Address - Country:US
Practice Address - Phone:214-220-2468
Practice Address - Fax:214-378-3325
Is Sole Proprietor?:No
Enumeration Date:2009-06-18
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.204435207X00000X
CT56732207X00000X
GA84354207X00000X
TXT0379207X00000X
LA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07436264Medicaid
LA1957780Medicaid
LA531377YH3UMedicare PIN