Basic Information
| Provider Information | |||||||||
| NPI: | 1013012897 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WASDAHL | ||||||||
| FirstName: | DANIEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 80690 | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308335530 | ||||||||
| FaxNumber: | 3308336085 | ||||||||
| Practice Location | |||||||||
| Address1: | 2600 6TH ST | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304386311 | ||||||||
| FaxNumber: | 3305805546 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 35-065405 | OH | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 0945884 | 05 | OH | MEDICAID |