Healthcare Provider Details

I. General information

NPI: 1104934199
Provider Name (Legal Business Name): WAYNE STUART GRADMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 12/22/2022
Certification Date: 12/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 S MCCARTY DR
BEVERLY HILLS CA
90212-3701
US

IV. Provider business mailing address

235 S MCCARTY DR
BEVERLY HILLS CA
90212-3701
US

V. Phone/Fax

Practice location:
  • Phone: 424-653-8560
  • Fax: 310-277-5045
Mailing address:
  • Phone: 424-653-8560
  • Fax: 310-277-5045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberG17696
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: