Provider Demographics
NPI:1295850410
Name:WADE, J KEITH (OD)
Entity Type:Individual
Prefix:DR
First Name:J
Middle Name:KEITH
Last Name:WADE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 LOCUST AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-4717
Mailing Address - Country:US
Mailing Address - Phone:304-366-2020
Mailing Address - Fax:304-367-0863
Practice Address - Street 1:405 LOCUST AVE
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-4717
Practice Address - Country:US
Practice Address - Phone:304-366-2020
Practice Address - Fax:304-367-0863
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV729OD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0150700000Medicaid
WV0150700000Medicaid
WV0313430001Medicare NSC
WVWA0579851Medicare PIN