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NPI Code Detail

MEDICARE: DR. ROY BRENT WADLE D.O.

MEDICARE: DR. ROY BRENT WADLE D.O.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine PhysicianK3520TX

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
145-2578435-002OTHERTXTRICARE
2752616977118OTHERTXTRICARE
3MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
40089BSOTHERTXBCBS
545-2578435-001OTHERTXTRICARE
68ED759OTHERTXBCBS

General Provider Information

NPI Number : 1194743278
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. ROY BRENT WADLE D.O.
Provider Business Mailing Address
First Line : PO BOX 846098
Second Line :
City : DALLAS
State : TX
Zip : 75284-6098
Country : US
Telephone Number : 903-324-6450
Fax Number :
Provider Business Practice Location Address
First Line : 8288 S BROADWAY AVE
Second Line :
City : TYLER
State : TX
Zip : 75703-5262
Country : US
Telephone Number : 903-606-7060
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/17/2006
Last Update Date : 04/08/2025

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