Provider Demographics
NPI:1619953478
Name:WADE, RONNIE D (O D)
Entity Type:Individual
Prefix:DR
First Name:RONNIE
Middle Name:D
Last Name:WADE
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 E COLFAX AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2804
Mailing Address - Country:US
Mailing Address - Phone:574-287-3333
Mailing Address - Fax:574-287-9999
Practice Address - Street 1:810 E COLFAX AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2804
Practice Address - Country:US
Practice Address - Phone:574-287-3333
Practice Address - Fax:574-287-9999
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-22
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001454AB152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100279980AMedicaid
INT35243Medicare UPIN
IN100279980AMedicaid
IN4686020001Medicare NSC