Provider Demographics
NPI:1043334089
Name:WADE, KELVIN C (MD)
Entity Type:Individual
Prefix:
First Name:KELVIN
Middle Name:C
Last Name:WADE
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 1:401 HALL ST STE A
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-7528
Mailing Address - Country:US
Mailing Address - Phone:318-324-9113
Mailing Address - Fax:318-329-9382
Practice Address - Street 1:401 HALL ST STE A
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-7528
Practice Address - Country:US
Practice Address - Phone:318-324-9113
Practice Address - Fax:318-329-9382
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11502R207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1664782Medicaid
LA1664782Medicaid
LAF62243Medicare UPIN