Provider Demographics
NPI:1679569594
Name:WADDELL, KEVIN RAY (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:RAY
Last Name:WADDELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:740 HOSPITAL DR
Mailing Address - Street 2:SUITE 250
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77701-4664
Mailing Address - Country:US
Mailing Address - Phone:409-212-1000
Mailing Address - Fax:409-813-3302
Practice Address - Street 1:740 HOSPITAL DR
Practice Address - Street 2:SUITE 250
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77701-4664
Practice Address - Country:US
Practice Address - Phone:409-212-1000
Practice Address - Fax:409-813-3302
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM4976207V00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX184821001Medicaid
TX8F4577Medicare PIN
TX184821001Medicaid