Provider Demographics
NPI:1982661542
Name:FATH, STEVEN WADE (MD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:WADE
Last Name:FATH
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 1:420 E 6TH ST STE 104
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-4537
Mailing Address - Country:US
Mailing Address - Phone:432-333-8400
Mailing Address - Fax:432-333-8401
Practice Address - Street 1:420 E 6TH ST STE 104
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4537
Practice Address - Country:US
Practice Address - Phone:432-333-8400
Practice Address - Fax:432-333-8401
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8144208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX040430302Medicaid
TXG10563Medicare UPIN
TXTXB124227Medicare PIN
TX040430302Medicaid