Provider Demographics
NPI:1386642635
Name:KONVALIN, WADE ALLEN (OD)
Entity Type:Individual
Prefix:DR
First Name:WADE
Middle Name:ALLEN
Last Name:KONVALIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:221 N PRESTON RD
Mailing Address - Street 2:STE B
Mailing Address - City:PROSPER
Mailing Address - State:TX
Mailing Address - Zip Code:75078-8792
Mailing Address - Country:US
Mailing Address - Phone:972-347-2020
Mailing Address - Fax:972-347-2072
Practice Address - Street 1:221 N PRESTON RD
Practice Address - Street 2:STE B
Practice Address - City:PROSPER
Practice Address - State:TX
Practice Address - Zip Code:75078-8792
Practice Address - Country:US
Practice Address - Phone:972-347-2020
Practice Address - Fax:972-347-2072
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX4286TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDQ7835OtherRAILROAD PTAN
TX4286TGOtherOPTOMETRY LICENSE
81503QOtherBLUE CROSS BLUE SHIELD
81503QOtherBLUE CROSS BLUE SHIELD
TXU11947Medicare UPIN
TX4286TGOtherOPTOMETRY LICENSE