Provider Demographics
NPI:1902241268
Name:WAVERLY, BRETT JOSEPH (DPM)
Entity Type:Individual
Prefix:DR
First Name:BRETT
Middle Name:JOSEPH
Last Name:WAVERLY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 NW ELKS DR
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-3758
Mailing Address - Country:US
Mailing Address - Phone:541-754-1150
Mailing Address - Fax:
Practice Address - Street 1:3680 NW SAMARITAN DR
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3737
Practice Address - Country:US
Practice Address - Phone:417-541-1505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-01
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005725213E00000X, 213ES0103X
WI1085-25213E00000X, 213ES0103X
ORDP201954213ES0103X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery