Provider Demographics
NPI:1861952624
Name:RETHERFORD, WAYDE TUCKER
Entity type:Individual
Prefix:MR
First Name:WAYDE
Middle Name:TUCKER
Last Name:RETHERFORD
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 1:4250 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32446-1917
Mailing Address - Country:US
Mailing Address - Phone:850-526-2200
Mailing Address - Fax:
Practice Address - Street 1:4318 5TH AVE
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-2182
Practice Address - Country:US
Practice Address - Phone:850-526-5300
Practice Address - Fax:850-526-2001
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME152692207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine