Healthcare Provider Details

I. General information

NPI: 1750403713
Provider Name (Legal Business Name): LISA F WADDELL M.D., M.P.H.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1751 CALHOUN ST
COLUMBIA SC
29201-2606
US

IV. Provider business mailing address

109 PEBBLE CREEK RD
COLUMBIA SC
29223-3112
US

V. Phone/Fax

Practice location:
  • Phone: 803-898-0800
  • Fax:
Mailing address:
  • Phone: 803-699-8126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number16993
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: