Healthcare Provider Details

I. General information

NPI: 1245216845
Provider Name (Legal Business Name): DOUGLAS A. WADESON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 12/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 S SALEM ST
APEX NC
27502-1825
US

IV. Provider business mailing address

212 S SALEM ST
APEX NC
27502-1825
US

V. Phone/Fax

Practice location:
  • Phone: 919-362-5201
  • Fax: 919-387-5905
Mailing address:
  • Phone: 919-362-5201
  • Fax: 919-387-5905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2014-00247
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier377344200
Identifier TypeMEDICAID
Identifier StateFL
Identifier Issuer
# 2
Identifier080075531
Identifier TypeOTHER
Identifier StateFL
Identifier IssuerRR MEDICARE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: