Provider Demographics
NPI:1629004684
Name:WADDLETON, BEVERLY L (DO)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:L
Last Name:WADDLETON
Suffix:
Gender:F
Credentials:DO
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 9477
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75711-9477
Mailing Address - Country:US
Mailing Address - Phone:903-594-2450
Mailing Address - Fax:903-509-0493
Practice Address - Street 1:108 PARKER ST
Practice Address - Street 2:STE.300
Practice Address - City:QUITMAN
Practice Address - State:TX
Practice Address - Zip Code:75783-2102
Practice Address - Country:US
Practice Address - Phone:903-763-6220
Practice Address - Fax:903-763-6222
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG0244207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00222535OtherMEDICARE RR
TX120495005Medicaid
TX8E0434Medicare PIN
D97810Medicare UPIN
P00222535OtherMEDICARE RR
TX8L1603Medicare PIN