Provider Demographics
NPI:1487810321
Name:WADE, ELLIOT LOUIS (MD)
Entity type:Individual
Prefix:
First Name:ELLIOT
Middle Name:LOUIS
Last Name:WADE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3022 S DURANGO DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-4439
Mailing Address - Country:US
Mailing Address - Phone:702-450-1717
Mailing Address - Fax:
Practice Address - Street 1:6970 W PATRICK LN
Practice Address - Street 2:SUITE 140
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89113-0269
Practice Address - Country:US
Practice Address - Phone:702-450-1717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-30
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA97317207R00000X
NV12770207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1487810321Medicaid