Healthcare Provider Details

I. General information

NPI: 1902393614
Provider Name (Legal Business Name): WILLIAM K WADE BOCP, COF, C.PED.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2018
Last Update Date: 04/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3004 BIENVILLE BLVD
OCEAN SPRINGS MS
39564-4370
US

IV. Provider business mailing address

3004 BIENVILLE BLVD
OCEAN SPRINGS MS
39564-4370
US

V. Phone/Fax

Practice location:
  • Phone: 228-875-3828
  • Fax: 228-436-3580
Mailing address:
  • Phone: 228-875-3828
  • Fax: 228-436-3580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberC50109
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code224L00000X
TaxonomyPedorthist
License NumberC50109
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberC50109
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: