Healthcare Provider Details

I. General information

NPI: 1043411168
Provider Name (Legal Business Name): DAVID A WADA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 05/26/2023
Certification Date: 05/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 N MEDICAL DR # E13
SALT LAKE CITY UT
84132-0001
US

IV. Provider business mailing address

50 N MEDICAL DR
SALT LAKE CITY UT
84132-0001
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-2955
  • Fax:
Mailing address:
  • Phone: 801-587-6340
  • Fax: 801-587-6346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number50181
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number5558245-1205
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number5558245-1205
License Number StateUT
# 5
Primary TaxonomyN
Taxonomy Code207ZP0104X
TaxonomyChemical Pathology Physician
License Number5558245-1205
License Number StateUT
# 6
Primary TaxonomyN
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number103224
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: