MEDICARE: DR. GREGORY J WASTEK M.D., PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	6905	NV
2	207N00000X	Dermatology Physician	G59991	CA
3	207ND0101X	MOHS-Micrographic Surgery Physician	6905	NV
4	207ND0101X	MOHS-Micrographic Surgery Physician	G59991	CA
5	207NP0225X	Pediatric Dermatology Physician	6905	NV
6	207NP0225X	Pediatric Dermatology Physician	G55591	CA
7	207NS0135X	Procedural Dermatology Physician	6905	NV
8	207NS0135X	Procedural Dermatology Physician	G59991	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	070014199	OTHER	NV	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1508833930
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GREGORY J WASTEK M.D., PH.D.

Provider Business Mailing Address
First Line	:	PO BOX 12060
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89112-0060
Country	:	US
Telephone Number	:	702-853-7451
Fax Number	:	909-557-1924

Provider Business Practice Location Address
First Line	:	6850 N DURANGO DR
Second Line	:	SUITE 100
City	:	LAS VEGAS
State	:	NV
Zip	:	89149-4595
Country	:	US
Telephone Number	:	702-589-3100
Fax Number	:	702-851-7725

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/03/2006
Last Update Date	:	02/01/2013

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Directions to “ DR. GREGORY J WASTEK M.D., PH.D.” Practice Location

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