Provider Demographics
NPI:1629135926
Name:WADE, KEVIN FRANCIS (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:FRANCIS
Last Name:WADE
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 1:1441 NE 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:PAYETTE
Mailing Address - State:ID
Mailing Address - Zip Code:83661-5420
Mailing Address - Country:US
Mailing Address - Phone:208-642-9376
Mailing Address - Fax:208-642-9959
Practice Address - Street 1:1219 SW 4TH AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-4566
Practice Address - Country:US
Practice Address - Phone:541-889-2668
Practice Address - Fax:541-889-2997
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD1960782080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100256720BMedicaid
OK731566286OtherEIN
OK731566286OtherEIN
OK100256720BMedicaid