Provider Demographics
NPI:1447222724
Name:GADE, JAY N (MD PHD)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:N
Last Name:GADE
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2440 NW EDENBOWER BLVD
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-8847
Mailing Address - Country:US
Mailing Address - Phone:541-957-1141
Mailing Address - Fax:541-957-1466
Practice Address - Street 1:2440 NW EDENBOWER BLVD
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-8847
Practice Address - Country:US
Practice Address - Phone:541-957-1141
Practice Address - Fax:541-957-1466
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD20360207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR150092Medicaid
G45559Medicare UPIN
ORR104076Medicare ID - Type Unspecified