Provider Demographics
NPI:1275591711
Name:DEMORDAUNT, WADE ROGER (OD)
Entity Type:Individual
Prefix:DR
First Name:WADE
Middle Name:ROGER
Last Name:DEMORDAUNT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 158
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-0158
Mailing Address - Country:US
Mailing Address - Phone:208-497-6406
Mailing Address - Fax:208-359-3007
Practice Address - Street 1:1450 N 2ND E
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-5131
Practice Address - Country:US
Practice Address - Phone:208-497-6406
Practice Address - Fax:208-359-3007
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-959152WC0802X
UT351670-9934152WC0802X
AZ1853152WC0802X
CA14349152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU65669Medicare UPIN