Provider Demographics
NPI:1174537906
Name:WADLEY, BYRON RICHARD (MD)
Entity type:Individual
Prefix:
First Name:BYRON
Middle Name:RICHARD
Last Name:WADLEY
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 1:3400 W MARSHALL AVE STE 430
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75604-5073
Mailing Address - Country:US
Mailing Address - Phone:903-297-9400
Mailing Address - Fax:903-297-3810
Practice Address - Street 1:3400 W MARSHALL AVE STE 430
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75604-5073
Practice Address - Country:US
Practice Address - Phone:903-297-9400
Practice Address - Fax:903-297-3810
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG02452084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX132886607Medicaid
TX132886607Medicaid
00435LMedicare Oscar/Certification