Provider Demographics
NPI:1609964683
Name:WADDELL, DAVID IRA (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:IRA
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 1:1050 RIVER OAKS DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9564
Mailing Address - Country:US
Mailing Address - Phone:601-420-0134
Mailing Address - Fax:601-420-0547
Practice Address - Street 1:1050 RIVER OAKS DR
Practice Address - Street 2:SUITE 200
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9564
Practice Address - Country:US
Practice Address - Phone:601-420-0134
Practice Address - Fax:601-420-0547
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13919207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSG16190Medicare UPIN
MS00115412Medicare ID - Type Unspecified