Healthcare Provider Details

I. General information

NPI: 1144239500
Provider Name (Legal Business Name): DAVID J WADDELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 08/01/2023
Certification Date: 08/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 SAPPINGTON BRIDGE RD
SULLIVAN MO
63080-2354
US

IV. Provider business mailing address

751 SAPPINGTON BRIDGE RD
SULLIVAN MO
63080-2354
US

V. Phone/Fax

Practice location:
  • Phone: 573-468-4186
  • Fax:
Mailing address:
  • Phone: 573-468-4186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2023006560
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number31608
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberE9142
License Number StateAR
# 4
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2023006560
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: