Healthcare Provider Details

I. General information

NPI: 1194723668
Provider Name (Legal Business Name): MICHAEL JAMES WADE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 04/30/2020
Certification Date: 04/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

791 ORCHARD ST
COACHELLA CA
92236-1730
US

IV. Provider business mailing address

PO BOX 10603
PALM DESERT CA
92255-0603
US

V. Phone/Fax

Practice location:
  • Phone: 760-398-0128
  • Fax: 760-398-0317
Mailing address:
  • Phone: 714-404-7041
  • Fax: 760-406-5697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A59820
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number20A5982
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: