Provider Demographics
NPI:1497735724
Name:WADDELL, JOHN J (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:J
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:PO BOX 7687
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65205-7687
Mailing Address - Country:US
Mailing Address - Phone:573-882-2259
Mailing Address - Fax:
Practice Address - Street 1:1125 MADISON ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-5227
Practice Address - Country:US
Practice Address - Phone:573-632-5265
Practice Address - Fax:573-632-5948
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5P32174400000X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS3239466BOtherRAILROAD MEDICARE- INDIV
KSCI2562OtherRAILROAD MEDICARE- GROUP
MOCI3618OtherRAILROAD MEDICARE- GROUP
MO792000001OtherTPAN CMS
MO3239466AOtherRAILROAD MEDICARE-INDIV
MO208691345Medicaid
MO208691345Medicaid
KSCI2562OtherRAILROAD MEDICARE- GROUP
MO3239466AMedicare PIN
MO792000001OtherTPAN CMS
MOP00479194Medicare PIN