Provider Demographics
NPI:1134120702
Name:INGRAM, WAYNE W (MD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:W
Last Name:INGRAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:WAYNE
Other - Middle Name:W
Other - Last Name:INGRAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:711 W 38TH ST
Mailing Address - Street 2:STE G4
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-1121
Mailing Address - Country:US
Mailing Address - Phone:512-458-1208
Mailing Address - Fax:512-458-1409
Practice Address - Street 1:711 W 38TH ST
Practice Address - Street 2:STE G4
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1121
Practice Address - Country:US
Practice Address - Phone:512-458-1208
Practice Address - Fax:512-458-1409
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE7995207VG0400X
TXE7795208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
C17299Medicare UPIN