Provider Demographics
NPI:1720013816
Name:WADDILL, JAMES ROGER (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:ROGER
Last Name:WADDILL
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 1:9001 SUMMA AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-3726
Mailing Address - Country:US
Mailing Address - Phone:225-761-5200
Mailing Address - Fax:
Practice Address - Street 1:3401 NORTH BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-3743
Practice Address - Country:US
Practice Address - Phone:225-336-3100
Practice Address - Fax:225-336-3111
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA17202207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1356476Medicaid
B64991Medicare UPIN
53988Medicare ID - Type Unspecified