Basic Information
Provider Information | |||||||||
NPI: | 1447292511 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WALDROP | ||||||||
FirstName: | PRESTON | ||||||||
MiddleName: | ADAM | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 8310 | ||||||||
Address2: |   | ||||||||
City: | ROANOKE | ||||||||
State: | VA | ||||||||
PostalCode: | 240140310 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5403453556 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 101 KNOTBREAK ROAD | ||||||||
Address2: |   | ||||||||
City: | SALEM | ||||||||
State: | VA | ||||||||
PostalCode: | 241537304 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5404444020 | ||||||||
FaxNumber: | 5404444021 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/12/2006 | ||||||||
LastUpdateDate: | 01/30/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | 0101046000 | VA | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
ID | Type | State | Issuer | Description | 3933260001 | 01 | VA | ADMINISTAR FEDERAL | OTHER | 006401104 | 05 | VA |   | MEDICAID | 200040420 | 01 | VA | RAILROAD MEDICARE | OTHER | 700201861 | 01 | VA | CIGNA | OTHER | 4409453 | 01 | VA | AETNA | OTHER | 127779 | 01 | VA | SOUTHERN HEALTH | OTHER | 286129 | 01 | VA | MAMSI | OTHER | 452548 | 01 | VA | ANTHEM | OTHER | 542006922 | 01 | VA | UNITED HEALTHCARE | OTHER |