Healthcare Provider Details

I. General information

NPI: 1104865674
Provider Name (Legal Business Name): DAVID A. WREDE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 09/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 VETERANS DR
LEXINGTON KY
40502-2235
US

IV. Provider business mailing address

765 WINTER HILL LN
LEXINGTON KY
40509-1961
US

V. Phone/Fax

Practice location:
  • Phone: 859-233-4511
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number21485
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number21485
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: