Provider Demographics
NPI:1275696908
Name:WASIAK, GARY ALAN (DPM)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:ALAN
Last Name:WASIAK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2997 E HIGHLAND RD
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48356-2811
Mailing Address - Country:US
Mailing Address - Phone:248-887-3729
Mailing Address - Fax:248-889-8910
Practice Address - Street 1:2997 E HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:MI
Practice Address - Zip Code:48356-2811
Practice Address - Country:US
Practice Address - Phone:248-887-3729
Practice Address - Fax:248-889-8910
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901000651213ES0103X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Not Answered213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1062554Medicaid
MI5825393OtherBCBSM
MI5825393OtherBCBSM
MIT34389Medicare UPIN