Basic Information
| Provider Information | |||||||||
| NPI: | 1205909793 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GARY L WADE MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1086 | ||||||||
| Address2: | |||||||||
| City: | YREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960971086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308427297 | ||||||||
| FaxNumber: | 5308429054 | ||||||||
| Practice Location | |||||||||
| Address1: | 444 BRUCE ST | ||||||||
| Address2: | |||||||||
| City: | YREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960973450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308427297 | ||||||||
| FaxNumber: | 5308429054 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 02/04/2008 | ||||||||
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| AuthorizedOfficialLastName: | WADE | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5308427297 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | GR0041660 | 05 | CA | MEDICAID |