Provider Demographics
NPI:1194743278
Name:WADLE, ROY BRENT (DO)
Entity type:Individual
Prefix:DR
First Name:ROY
Middle Name:BRENT
Last Name:WADLE
Suffix:
Gender:
Credentials:DO
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 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:8288 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-5262
Practice Address - Country:US
Practice Address - Phone:903-606-7060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK3520207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45-2578435-002OtherTRICARE
TX752616977118OtherTRICARE
TX111773104Medicaid
TX0089BSOtherBCBS
TX45-2578435-001OtherTRICARE
TX8ED759OtherBCBS
TX752616977118OtherTRICARE
TX111773104Medicaid
TX8ED759OtherBCBS
TXP00335388Medicare PIN
TX8G7607Medicare PIN