Provider Demographics
NPI:1598758849
Name:WADDELL, DAVID D (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
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 1:6999 BICKHAM RD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-8398
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6999 BICKHAM RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-8398
Practice Address - Country:US
Practice Address - Phone:318-929-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.012603207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA200016145Medicare PIN
LAB60422Medicare UPIN
LA5J326B103Medicare PIN
LA5J326B103Medicare ID - Type Unspecified