Provider Demographics
NPI:1538111851
Name:WARDELL, WALTER JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:JOHN
Last Name:WARDELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 896206
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-6206
Mailing Address - Country:US
Mailing Address - Phone:252-447-7088
Mailing Address - Fax:252-447-2752
Practice Address - Street 1:532 WEBB BLVD
Practice Address - Street 2:
Practice Address - City:HAVELOCK
Practice Address - State:NC
Practice Address - Zip Code:28532-2042
Practice Address - Country:US
Practice Address - Phone:252-447-7088
Practice Address - Fax:252-447-2752
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC36849207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8907640Medicaid
NCF54315Medicare UPIN
NCF54315Medicare UPIN