=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407964463
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DARRELL D WADAS MD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2006
-----------------------------------------------------
Last Update Date | 11/21/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1300 N 12TH ST #603
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85006-2850
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-254-6686
-----------------------------------------------------
Fax | 602-254-4258
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1300 N 12TH ST #603
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85006-2850
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-254-6686
-----------------------------------------------------
Fax | 602-254-4258
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DARRELL D WADAS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 602-254-6686
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 13563
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------