Basic Information
| Provider Information | |||||||||
| NPI: | 1679569594 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WADDELL | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | RAY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 740 HOSPITAL DR | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777014664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4092121000 | ||||||||
| FaxNumber: | 4098133302 | ||||||||
| Practice Location | |||||||||
| Address1: | 740 HOSPITAL DR | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777014664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4092121000 | ||||||||
| FaxNumber: | 4098133302 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2005 | ||||||||
| LastUpdateDate: | 11/19/2018 | ||||||||
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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 | 207V00000X | M4976 | TX | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 184821001 | 05 | TX | MEDICAID |