Healthcare Provider Details

I. General information

NPI: 1811381379
Provider Name (Legal Business Name): BENJAMIN R WADDELL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2015
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 ANNE ST NW
BEMIDJI MN
56601-5103
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 218-333-5000
  • Fax:
Mailing address:
  • Phone: 605-328-6585
  • Fax: 605-328-6512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0102205173
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: