Healthcare Provider Details

I. General information

NPI: 1942367750
Provider Name (Legal Business Name): MICHAEL G WAYNE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 04/24/2023
Certification Date: 04/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 6TH ST DEPT
BROOKLYN NY
11215-3609
US

IV. Provider business mailing address

152 WOOSTER ST APT 2A
NEW YORK NY
10012-5331
US

V. Phone/Fax

Practice location:
  • Phone: 718-780-3288
  • Fax: 718-780-3154
Mailing address:
  • Phone: 914-345-0545
  • Fax: 212-604-3383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number203000
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number203000
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number203000
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: