Provider Demographics
NPI:1962466912
Name:WADDELL, MARTHA M
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:M
Last Name:WADDELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:M
Other - Last Name:WADDELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 173862
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-3862
Mailing Address - Country:US
Mailing Address - Phone:303-306-7783
Mailing Address - Fax:303-306-7753
Practice Address - Street 1:501 E HAMPDEN AVE
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113-2702
Practice Address - Country:US
Practice Address - Phone:303-788-6911
Practice Address - Fax:303-306-7753
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2015-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO42011207Q00000X
CODR.0042011208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO32778845Medicaid
COP01278201OtherRAILROAD MEDICARE
CO32778845Medicaid
COCOAAA4135Medicare PIN
COP01278201OtherRAILROAD MEDICARE
CO542198Medicare ID - Type Unspecified