Healthcare Provider Details

I. General information

NPI: 1447256953
Provider Name (Legal Business Name): RALPH DAVID WADE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 08/24/2009
Certification Date:
Deactivation Date: 03/21/2006
Reactivation Date: 04/05/2006

III. Provider practice location address

557 W 2600 S
BOUNTIFUL UT
84010-7747
US

IV. Provider business mailing address

557 W 2600 S
BOUNTIFUL UT
84010-7747
US

V. Phone/Fax

Practice location:
  • Phone: 801-298-9155
  • Fax: 801-298-9156
Mailing address:
  • Phone: 801-298-9155
  • Fax: 801-298-9156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number180211-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: