Provider Demographics
NPI:1619042470
Name:CAIN, JOHN WALLACE II (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WALLACE
Last Name:CAIN
Suffix:II
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 1:1404 WINTER DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-2530
Mailing Address - Country:US
Mailing Address - Phone:615-790-2900
Mailing Address - Fax:615-599-0718
Practice Address - Street 1:930 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-5136
Practice Address - Country:US
Practice Address - Phone:615-673-6737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD 0166242084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN04720840061OtherME #
TNE50225Medicare UPIN
TN3044131Medicare ID - Type Unspecified