Basic Information
| Provider Information | |||||||||
| NPI: | 1801030440 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROBERT L WADDELL MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 1660 | ||||||||
| Address2: | |||||||||
| City: | ADA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748211660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803100102 | ||||||||
| FaxNumber: | 5803100104 | ||||||||
| Practice Location | |||||||||
| Address1: | 435 N. MONTE VISTA | ||||||||
| Address2: | |||||||||
| City: | ADA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748204676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803100102 | ||||||||
| FaxNumber: | 5803100104 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2009 | ||||||||
| LastUpdateDate: | 05/26/2011 | ||||||||
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| AuthorizedOfficialLastName: | WADDELL | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | LUTHER | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5803100102 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 20345 | OK | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 100155110A | 05 | OK | MEDICAID |