Provider Demographics
NPI:1023008018
Name:WAXMAN, GARY JAY (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:JAY
Last Name:WAXMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 INDEPENDENCE BLVD
Mailing Address - Street 2:STE 2A
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-6010
Mailing Address - Country:US
Mailing Address - Phone:757-363-6712
Mailing Address - Fax:757-363-6204
Practice Address - Street 1:816 INDEPENDENCE BLVD
Practice Address - Street 2:STE 2A
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-6010
Practice Address - Country:US
Practice Address - Phone:757-363-6712
Practice Address - Fax:757-363-6204
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2009-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101059225207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010125529Medicaid
006607557Medicare ID - Type Unspecified
VA010125529Medicaid