Provider Demographics
NPI:1437345642
Name:EADES, KEN STEVE (MD)
Entity Type:Individual
Prefix:DR
First Name:KEN
Middle Name:STEVE
Last Name:EADES
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 1:815 SANTA FE DR
Mailing Address - Street 2:100
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76086-6522
Mailing Address - Country:US
Mailing Address - Phone:817-341-2861
Mailing Address - Fax:817-341-3603
Practice Address - Street 1:815 SANTA FE DR
Practice Address - Street 2:100
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-6522
Practice Address - Country:US
Practice Address - Phone:817-341-2861
Practice Address - Fax:817-341-3603
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-20
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE3903174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXB22431Medicare UPIN