Provider Demographics
NPI:1033103643
Name:WADDINGTON, GARY LEE (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:LEE
Last Name:WADDINGTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:14239 W BELL RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-2469
Mailing Address - Country:US
Mailing Address - Phone:623-544-7755
Mailing Address - Fax:623-544-8665
Practice Address - Street 1:14239 W BELL RD
Practice Address - Street 2:SUITE 101
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-2469
Practice Address - Country:US
Practice Address - Phone:623-544-7755
Practice Address - Fax:623-544-8665
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12916207KA0200X, 207N00000X, 207K00000X, 207NI0002X, 207NS0135X, 207ND0900X, 207ND0101X, 207NP0225X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ07WCKGC03Medicare PIN
AZ07WCHBH03Medicare PIN
D00524Medicare UPIN
AZ07WCKGD03Medicare PIN