Provider Demographics
NPI:1629029806
Name:WADDELL, GARY M (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:M
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 1:4777 US HIGHWAY 259
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-7668
Mailing Address - Country:US
Mailing Address - Phone:903-663-4800
Mailing Address - Fax:903-663-0378
Practice Address - Street 1:2900 S LOOP 256
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-6958
Practice Address - Country:US
Practice Address - Phone:903-731-1084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK17162085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX102048902Medicaid
TX102048902Medicaid
TX81851KMedicare ID - Type Unspecified