Provider Demographics
NPI:1932413267
Name:WADDELL, HEITH L (MD)
Entity type:Individual
Prefix:MR
First Name:HEITH
Middle Name:L
Last Name:WADDELL
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 517
Mailing Address - Street 2:713 OAK STREET
Mailing Address - City:SUNDANCE
Mailing Address - State:WY
Mailing Address - Zip Code:82729-0517
Mailing Address - Country:US
Mailing Address - Phone:307-283-3501
Mailing Address - Fax:307-283-2255
Practice Address - Street 1:1041 MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:CUSTER
Practice Address - State:SD
Practice Address - Zip Code:57730-1304
Practice Address - Country:US
Practice Address - Phone:605-673-4150
Practice Address - Fax:605-673-3917
Is Sole Proprietor?:No
Enumeration Date:2010-07-28
Last Update Date:2020-03-31
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Provider Licenses
StateLicense IDTaxonomies
SD8880207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY135583000Medicaid