Provider Demographics
NPI:1326087487
Name:WADE, JOHN L (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:L
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 1:100 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-5004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:688 KINOOLE ST STE 103
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-3868
Practice Address - Country:US
Practice Address - Phone:808-969-8010
Practice Address - Fax:903-663-7394
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME784732085R0202X
VTFF05326892085R0202X
HIMD203492085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
5850615OtherAETNA PPO
FL256907800Medicaid
2193139OtherAETNA HMO
46845OtherBCBS
ME78473OtherFLORIDA LICENSE
ME78473OtherFLORIDA LICENSE
5850615OtherAETNA PPO