Healthcare Provider Details

I. General information

NPI: 1720013816
Provider Name (Legal Business Name): JAMES ROGER WADDILL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 12/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 NORTH BLVD
BATON ROUGE LA
70806-3743
US

IV. Provider business mailing address

9001 SUMMA AVE
BATON ROUGE LA
70809-3726
US

V. Phone/Fax

Practice location:
  • Phone: 225-336-3100
  • Fax: 225-336-3111
Mailing address:
  • Phone: 225-761-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number17202
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: