Provider Demographics
NPI:1083677959
Name:WADDELL, BARRY LEE (MD)
Entity type:Individual
Prefix:
First Name:BARRY
Middle Name:LEE
Last Name:WADDELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5280
Mailing Address - Street 2:PATIENT BUSIENSS SERVICES
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95150-5280
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:751 S BASCOM AVE
Practice Address - Street 2:ANESTHESIOLOGY DEPARTMENT
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-2604
Practice Address - Country:US
Practice Address - Phone:408-885-5745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA83161207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A831610Medicaid
CA00A831610Medicare PIN
CA00A831610Medicaid