Provider Demographics
NPI:1427040112
Name:WINE, JOHN R
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:R
Last Name:WINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 927
Mailing Address - Street 2:
Mailing Address - City:WHITE SULPHUR SPRINGS
Mailing Address - State:WV
Mailing Address - Zip Code:24986-2373
Mailing Address - Country:US
Mailing Address - Phone:304-536-5030
Mailing Address - Fax:304-536-5031
Practice Address - Street 1:412 NAMOZINE STREET
Practice Address - Street 2:
Practice Address - City:BURKEVILLE
Practice Address - State:VA
Practice Address - Zip Code:23922
Practice Address - Country:US
Practice Address - Phone:434-767-4822
Practice Address - Fax:434-767-2211
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2011-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101029100207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA345648OtherANTHEM
VA1108312OtherCIGNA
VA1427040112Medicaid
VA4468872OtherAETNA
VA5633419Medicaid
VA61459602OtherBLACK LUNG/FECA
VA345648OtherANTHEM
VA080001632Medicare ID - Type UnspecifiedVA MEDICARE NUMBER
VA1427040112Medicaid
VA00X677C13Medicare PIN