Provider Demographics
NPI:1083655781
Name:WANERKA, GARY R (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:R
Last Name:WANERKA
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 1:784 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-2918
Mailing Address - Country:US
Mailing Address - Phone:203-481-7008
Mailing Address - Fax:203-315-2712
Practice Address - Street 1:784 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-2918
Practice Address - Country:US
Practice Address - Phone:203-481-7008
Practice Address - Fax:203-315-2712
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0131852080A0000X, 2080P0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
No2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001131853Medicaid
CTB84582Medicare UPIN