Healthcare Provider Details

I. General information

NPI: 1033103643
Provider Name (Legal Business Name): GARY LEE WADDINGTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 05/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14239 W BELL RD SUITE 101
SURPRISE AZ
85374-2469
US

IV. Provider business mailing address

14239 W BELL RD SUITE 101
SURPRISE AZ
85374-2469
US

V. Phone/Fax

Practice location:
  • Phone: 623-544-7755
  • Fax: 623-544-8665
Mailing address:
  • Phone: 623-544-7755
  • Fax: 623-544-8665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number12916
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number12916
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number12916
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License Number12916
License Number StateAZ
# 5
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number12916
License Number StateAZ
# 6
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number12916
License Number StateAZ
# 7
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number12916
License Number StateAZ
# 8
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number12916
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: