Provider Demographics
NPI:1376512137
Name:WADE, MARK D (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:WADE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:211 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6220
Mailing Address - Country:US
Mailing Address - Phone:314-336-4690
Mailing Address - Fax:800-432-6004
Practice Address - Street 1:12601 OLIVE BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6313
Practice Address - Country:US
Practice Address - Phone:314-336-4690
Practice Address - Fax:800-432-6004
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02999152W00000X
IL046-008455152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO313117905Medicaid
MO4210OtherMISSOURI MEDICAID
108459OtherBLUE CROSS BLUE SHIELD MO
MO313117913Medicaid
22-01100OtherUNITED HEALTHCARE
237550OtherHELATHLINK
IL046008455Medicaid
222865OtherGROUP HEALTH PLAN
116865OtherEYEMED
12139OtherOPTICARE MEDICARE COMPLET
IL410048083OtherRR MEDICARE
U27017Medicare UPIN
MO000091343Medicare PIN
IL046008455Medicaid
MO000091354Medicare PIN