Provider Demographics
NPI:1750311833
Name:WEDLAKE, PATRICK J (DO)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:J
Last Name:WEDLAKE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 SISKIYOU BLVD
Mailing Address - Street 2:SUITE 7
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-2237
Mailing Address - Country:US
Mailing Address - Phone:541-482-0342
Mailing Address - Fax:541-482-6986
Practice Address - Street 1:850 SISKIYOU BLVD
Practice Address - Street 2:SUITE 7
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-2237
Practice Address - Country:US
Practice Address - Phone:541-482-0342
Practice Address - Fax:541-482-6986
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO16364204D00000X
CO28988204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR012828Medicaid
ORE40377Medicare UPIN
OR012828Medicaid