Basic Information
| Provider Information | |||||||||
| NPI: | 1972582237 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEDDLE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | PALMER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3500 WE KNIGHT DR | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729036248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797098686 | ||||||||
| FaxNumber: | 4797098687 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 S J T STITES ST | ||||||||
| Address2: | |||||||||
| City: | SALLISAW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 749559302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187759159 | ||||||||
| FaxNumber: | 4797098687 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2006 | ||||||||
| LastUpdateDate: | 08/19/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | E-1681 | AR | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 3297 | OK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 930089348 | 01 | AR | RR MEDICARE | OTHER | 100077380A | 05 | OK | MEDICAID | 134699003 | 05 | AR | MEDICAID | 5K787 | 01 | AR | BLUECROSS BLUESHIELD | OTHER |