Provider Demographics
NPI:1750485058
Name:WADDELL, ROBERT LUTHER (MD)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:LUTHER
Last Name:WADDELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:530 N MONTE VISTA ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-4675
Mailing Address - Country:US
Mailing Address - Phone:580-436-7101
Mailing Address - Fax:580-436-4447
Practice Address - Street 1:435 N MONTE VISTA
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820
Practice Address - Country:US
Practice Address - Phone:580-310-0102
Practice Address - Fax:580-310-0104
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK20345208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK10015510AMedicaid
B27385Medicare UPIN