| Doctor Name: | DR. DOUGLAS WAYNE SODERDAHL |
| NPI Number: | 1245217769 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | M.D. |
| License Number: | 0101233888 |
| Business Practice Address: | 3851 Roger Brooke Drive Mche-qd Fort Sam Houston, TX - 782346200 |
| Business Phone Number: | 2109162460 |
| Business Fax Number: | |
| Mailing Address: | 3851 Roger Brooke Drive, Mche-qd FORT SAM HOUSTON |
| State: | TX |
| Postal Code: | 782346200 |
| Phone Number: | 2109162460 |
| Fax Number: | |
| NPI Enumeration Date: | 12/27/2005 |
| NPI Last Update Date: | 05/13/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 171000000X |
| License Number: | 0101233888 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | VA |
| Taxonomy Type: | Other Service Providers |
| Taxonomy Classification: | Military Health Care Provider |
| Taxonomy Specialization: | |
| Taxonomy Definition: | Active duty military health care providers not otherwise classified who need to be separately identified for operational, clinical, or administrative processes. |