MEDICARE: DR. WAYNE R SEBASTIANO M.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	207Q00000X	Family Medicine Physician	168147	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0110804	OTHER		GHI
2	04F91	OTHER	NY	BC/BS PROVIDER ID
3	AP133	OTHER	NY	OXFORD ID

General Provider Information

NPI Number	:	1841238722
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WAYNE R SEBASTIANO M.D.

Provider Business Mailing Address
First Line	:	7801 MYRTLE AVE
Second Line	:
City	:	GLENDALE
State	:	NY
Zip	:	11385-7439
Country	:	US
Telephone Number	:	718-386-8300
Fax Number	:	718-386-0437

Provider Business Practice Location Address
First Line	:	7801 MYRTLE AVE
Second Line	:
City	:	GLENDALE
State	:	NY
Zip	:	11385-7439
Country	:	US
Telephone Number	:	718-386-8300
Fax Number	:	718-386-0437

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

Provider Enumeration Date	:	06/03/2006
Last Update Date	:	05/10/2013

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