Provider Demographics
NPI:1104816321
Name:SHADE, WILLIAM A
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:A
Last Name:SHADE
Suffix:
Gender:M
Credentials:
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 1821
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43702-1821
Mailing Address - Country:US
Mailing Address - Phone:740-455-3342
Mailing Address - Fax:740-455-3686
Practice Address - Street 1:945 BETHESDA DR
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-0801
Practice Address - Country:US
Practice Address - Phone:740-455-4530
Practice Address - Fax:740-454-4647
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35060439207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0815809Medicaid
OHSH0694609Medicare ID - Type Unspecified
OH0815809Medicaid