Healthcare Provider Details

I. General information

NPI: 1154499002
Provider Name (Legal Business Name): WILLIAM R WADLAND MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 10/01/2020
Certification Date: 10/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 VERANDA ST
PORTLAND ME
04103-5545
US

IV. Provider business mailing address

PO BOX 9746
PORTLAND ME
04104-5040
US

V. Phone/Fax

Practice location:
  • Phone: 207-828-2402
  • Fax: 207-828-2425
Mailing address:
  • Phone: 207-791-3888
  • Fax: 207-828-7850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number017302
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number017302
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: