Provider Demographics
NPI:1609862242
Name:WADA, JANE SHOW (MD)
Entity Type:Individual
Prefix:MRS
First Name:JANE
Middle Name:SHOW
Last Name:WADA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2103 MONTROSE AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:MONTROSE
Mailing Address - State:CA
Mailing Address - Zip Code:91020-1546
Mailing Address - Country:US
Mailing Address - Phone:818-957-2066
Mailing Address - Fax:818-957-0689
Practice Address - Street 1:2103 MONTROSE AVE
Practice Address - Street 2:SUITE D
Practice Address - City:MONTROSE
Practice Address - State:CA
Practice Address - Zip Code:91020-1546
Practice Address - Country:US
Practice Address - Phone:818-957-2066
Practice Address - Fax:818-957-0689
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG30116207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG30116Medicare ID - Type Unspecified
CAA44291Medicare UPIN