Provider Demographics
NPI:1104913995
Name:WADDELL, RICHARD ALLEN (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ALLEN
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 1:2330 NW 99TH ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98117-2525
Mailing Address - Country:US
Mailing Address - Phone:206-789-8038
Mailing Address - Fax:
Practice Address - Street 1:1550 N 115TH ST
Practice Address - Street 2:MAIL STOP: D-149
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98133-8401
Practice Address - Country:US
Practice Address - Phone:206-368-1849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00042822207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8389868Medicaid
8856272Medicare ID - Type Unspecified
WA8389868Medicaid