Healthcare Provider Details

I. General information

NPI: 1932413267
Provider Name (Legal Business Name): HEITH L WADDELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2010
Last Update Date: 03/31/2020
Certification Date: 03/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1041 MONTGOMERY ST
CUSTER SD
57730-1304
US

IV. Provider business mailing address

PO BOX 517 713 OAK STREET
SUNDANCE WY
82729-0517
US

V. Phone/Fax

Practice location:
  • Phone: 605-673-4150
  • Fax: 605-673-3917
Mailing address:
  • Phone: 307-283-3501
  • Fax: 307-283-2255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number8880
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: