Provider Demographics
NPI:1134219447
Name:WADE, JEFFREY SCOTT (OD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:SCOTT
Last Name:WADE
Suffix:
Gender:
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50571 PRESTONWOOD CT
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-4963
Mailing Address - Country:US
Mailing Address - Phone:574-274-0117
Mailing Address - Fax:574-875-5171
Practice Address - Street 1:155 E UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-4474
Practice Address - Country:US
Practice Address - Phone:574-243-7732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-15
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002947B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200204300AMedicaid
IN35-2132356OtherTAX ID#
IN261410AMedicare PIN