Provider Demographics
NPI:1578551149
Name:WAID, HARLAN SAMPLE JR (MD)
Entity Type:Individual
Prefix:DR
First Name:HARLAN
Middle Name:SAMPLE
Last Name:WAID
Suffix:JR
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 1:125 S CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:OH
Mailing Address - Zip Code:44047-1312
Mailing Address - Country:US
Mailing Address - Phone:440-576-9111
Mailing Address - Fax:
Practice Address - Street 1:125 S CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:OH
Practice Address - Zip Code:44047-1312
Practice Address - Country:US
Practice Address - Phone:440-576-9111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2012-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35047304207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0483838Medicaid
OHA15084Medicare UPIN
OH0483838Medicaid