Provider Demographics
NPI:1427301035
Name:PATRICK J WEDLAKE DO PC
Entity type:Organization
Organization Name:PATRICK J WEDLAKE DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:WEDLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:541-864-0278
Mailing Address - Street 1:850 SISKIYOU BLVD
Mailing Address - Street 2:STE 7
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-2125
Mailing Address - Country:US
Mailing Address - Phone:541-482-0342
Mailing Address - Fax:541-482-6986
Practice Address - Street 1:85O SISKIYOU BLVD
Practice Address - Street 2:STE 9
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-2125
Practice Address - Country:US
Practice Address - Phone:541-482-0342
Practice Address - Fax:541-482-6986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-19
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO16364204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR012828Medicaid
OR012828Medicaid