Provider Demographics
NPI:1871645614
Name:TADE, DARRELL L (OD)
Entity type:Individual
Prefix:DR
First Name:DARRELL
Middle Name:L
Last Name:TADE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 CAMPBELL LN STE 120
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-1085
Mailing Address - Country:US
Mailing Address - Phone:270-781-3937
Mailing Address - Fax:270-783-3435
Practice Address - Street 1:760 CAMPBELL LN STE 120
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-1085
Practice Address - Country:US
Practice Address - Phone:270-781-3937
Practice Address - Fax:270-783-3435
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1142DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77011427Medicaid
KY77011427Medicaid
KYU3002Medicare UPIN