Provider Demographics
NPI:1558330373
Name:WADDELL, ROGER D (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:D
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 1:211 BROOK RD
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:NC
Mailing Address - Zip Code:28315-3125
Mailing Address - Country:US
Mailing Address - Phone:910-944-7777
Mailing Address - Fax:910-944-9663
Practice Address - Street 1:211 BROOK RD
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:NC
Practice Address - Zip Code:28315-3125
Practice Address - Country:US
Practice Address - Phone:910-944-7777
Practice Address - Fax:910-944-9663
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC30105207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2032278Medicare ID - Type Unspecified