Basic Information
Provider Information | |||||||||
NPI: | 1144239500 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WADDELL | ||||||||
FirstName: | DAVID | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 860 HIGHWAY 62 E STE 10 | ||||||||
Address2: |   | ||||||||
City: | MOUNTAIN HOME | ||||||||
State: | AR | ||||||||
PostalCode: | 726533200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8704243181 | ||||||||
FaxNumber: | 8704243089 | ||||||||
Practice Location | |||||||||
Address1: | 624 HOSPITAL DR | ||||||||
Address2: |   | ||||||||
City: | MOUNTAIN HOME | ||||||||
State: | AR | ||||||||
PostalCode: | 726532955 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8705081000 | ||||||||
FaxNumber: | 8704243089 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/05/2006 | ||||||||
LastUpdateDate: | 03/07/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/07/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | 31608 | IA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 208M00000X | E9142 | AR | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | 419099YWUJ | 01 | AR | MEDICARE | OTHER | 0148593 | 05 | IA |   | MEDICAID | 110149386 | 01 | IA | RR MEDICARE | OTHER | 209747001 | 05 | AR |   | MEDICAID | 208691204 | 05 | MO |   | MEDICAID | 421202636 | 01 | IA | TAX ID | OTHER |