Basic Information
Provider Information | |||||||||
NPI: | 1639251051 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KEVIN R WADDELL MD PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 740 HOSPITAL DR | ||||||||
Address2: | SUITE 250 | ||||||||
City: | BEAUMONT | ||||||||
State: | TX | ||||||||
PostalCode: | 777014664 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4092121000 | ||||||||
FaxNumber: | 4092121003 | ||||||||
Practice Location | |||||||||
Address1: | 740 HOSPITAL DR | ||||||||
Address2: | SUITE 250 | ||||||||
City: | BEAUMONT | ||||||||
State: | TX | ||||||||
PostalCode: | 777014664 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4092121000 | ||||||||
FaxNumber: | 4092121003 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/19/2006 | ||||||||
LastUpdateDate: | 09/26/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WADDELL | ||||||||
AuthorizedOfficialFirstName: | KEVIN | ||||||||
AuthorizedOfficialMiddleName: | R. | ||||||||
AuthorizedOfficialTitleorPosition: | PROVIDER | ||||||||
AuthorizedOfficialTelephone: | 4092121000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | M4976 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 184820201 | 05 | TX |   | MEDICAID | 184820202 | 05 | TX |   | MEDICAID |