Provider Demographics
NPI:1669696076
Name:WADE, TWILA V (DO)
Entity type:Individual
Prefix:DR
First Name:TWILA
Middle Name:V
Last Name:WADE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3012 SHADY KNOLL LN
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76021-4120
Mailing Address - Country:US
Mailing Address - Phone:817-485-8346
Mailing Address - Fax:
Practice Address - Street 1:3012 SHADY KNOLL LN
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-4120
Practice Address - Country:US
Practice Address - Phone:817-485-8346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF20852085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXA67755Medicare UPIN