Provider Demographics
NPI:1386641249
Name:WADHVANIA, SAM WADE (MD)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:WADE
Last Name:WADHVANIA
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:P.O. BOX 9677
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-9677
Mailing Address - Country:US
Mailing Address - Phone:866-500-7071
Mailing Address - Fax:866-500-7081
Practice Address - Street 1:1200 E 3900 S
Practice Address - Street 2:SUITE 4B
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1300
Practice Address - Country:US
Practice Address - Phone:866-500-7071
Practice Address - Fax:866-500-7081
Is Sole Proprietor?:No
Enumeration Date:2005-07-06
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6405008-1205208M00000X
PAMD 420995207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1009459080001Medicaid
PA1009459080001Medicaid
UT000060549Medicare PIN
PAWA074851Medicare ID - Type Unspecified