Provider Demographics
NPI:1053440099
Name:GARD, DWAYNE THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:DWAYNE
Middle Name:THOMAS
Last Name:GARD
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 1:4700 WATERS AVE
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-6220
Mailing Address - Country:US
Mailing Address - Phone:912-350-2155
Mailing Address - Fax:912-350-2156
Practice Address - Street 1:4700 WATERS AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-6220
Practice Address - Country:US
Practice Address - Phone:912-350-2155
Practice Address - Fax:912-350-2156
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC127604207R00000X
GA060731208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA721978496AMedicaid
GA466640OtherWELLCARE
SCG60731Medicaid
01352254OtherAMERIGROUP
GA721978496BMedicaid
GAP00803304OtherRR MEDICARE
GAP00609441OtherRR MEDICARE
GA721978496AMedicaid
GA721978496BMedicaid