Basic Information
| Provider Information | |||||||||
| NPI: | 1215991476 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WADDELL | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | ALLEN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 559 VINCENT ST | ||||||||
| Address2: | ATTN: 21 AMDS/SGPF - AEROSP MED | ||||||||
| City: | PETERSON AFB | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809141540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195561260 | ||||||||
| FaxNumber: | 8668677926 | ||||||||
| Practice Location | |||||||||
| Address1: | 559 VINCENT ST | ||||||||
| Address2: | ATTN: 21 AMDS/SGPF - AEROSP MED | ||||||||
| City: | PETERSON AFB | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809141540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195561260 | ||||||||
| FaxNumber: | 8668677926 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2006 | ||||||||
| LastUpdateDate: | 03/25/2011 | ||||||||
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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 | 207Q00000X | 07731 | MS | N | Allopathic & Osteopathic Physicians | Family Medicine | 2083A0100X | 07731 | MS | Y | Allopathic & Osteopathic Physicians | Preventive Medicine | Aerospace Medicine |
No ID Information.