Provider Demographics
NPI:1841282324
Name:WADE, JOHN R (OD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:WADE
Suffix:
Gender:M
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:PO BOX 149
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47006-0149
Mailing Address - Country:US
Mailing Address - Phone:812-934-2117
Mailing Address - Fax:812-933-0913
Practice Address - Street 1:1049 STATE ROAD 229
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:IN
Practice Address - Zip Code:47006-6808
Practice Address - Country:US
Practice Address - Phone:812-934-2117
Practice Address - Fax:812-933-0913
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-19
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ININ 1811152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100051770Medicaid
IL000000031291OtherANTHEM
IN410048459OtherRAILROAD MEDICARE
IN0328580001Medicare NSC
IL000000031291OtherANTHEM
052820Medicare PIN