Provider Demographics
NPI:1346427069
Name:SKARDOUTOS, WADE THOMAS (CP)
Entity Type:Individual
Prefix:
First Name:WADE
Middle Name:THOMAS
Last Name:SKARDOUTOS
Suffix:
Gender:M
Credentials:CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3350 SCOTT BLVD STE 6301
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95054-3125
Mailing Address - Country:US
Mailing Address - Phone:408-845-9245
Mailing Address - Fax:408-845-9259
Practice Address - Street 1:3350 SCOTT BLVD STE 6301
Practice Address - Street 2:191 SAN FELIPE RD. STE M1 HOLLISTER, CA 95023
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95054
Practice Address - Country:US
Practice Address - Phone:408-845-9245
Practice Address - Fax:408-845-9259
Is Sole Proprietor?:No
Enumeration Date:2008-01-24
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICP003200224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
5579810001Medicare NSC
5579810002Medicare NSC