Provider Demographics
NPI:1568462828
Name:WADE, DAVID GLEN (DPM)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:GLEN
Last Name:WADE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 269092
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126-9092
Mailing Address - Country:US
Mailing Address - Phone:405-947-8041
Mailing Address - Fax:405-947-8043
Practice Address - Street 1:3330 NW 56TH ST
Practice Address - Street 2:SUITE 600
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4479
Practice Address - Country:US
Practice Address - Phone:405-947-8041
Practice Address - Fax:405-947-8043
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK120213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKT40777Medicare UPIN
OK420744ZPYEMedicare PIN