Healthcare Provider Details

I. General information

NPI: 1558452961
Provider Name (Legal Business Name): WADE TRAVIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 LITTLE OAK WAY
ROUND ROCK TX
78681-5516
US

IV. Provider business mailing address

1001 LITTLE OAK WAY
ROUND ROCK TX
78681-5516
US

V. Phone/Fax

Practice location:
  • Phone: 512-255-8868
  • Fax: 512-255-8869
Mailing address:
  • Phone: 512-255-8868
  • Fax: 512-255-8869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberK5721
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: