Provider Demographics
NPI:1326100249
Name:CALLEN, WAYNE LEON (MD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:LEON
Last Name:CALLEN
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 1:825 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:LEADVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80461-2205
Mailing Address - Country:US
Mailing Address - Phone:719-486-1264
Mailing Address - Fax:719-486-1286
Practice Address - Street 1:825 W 6TH ST
Practice Address - Street 2:
Practice Address - City:LEADVILLE
Practice Address - State:CO
Practice Address - Zip Code:80461-2205
Practice Address - Country:US
Practice Address - Phone:719-486-1264
Practice Address - Fax:719-486-1286
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01220813Medicaid
CO804489Medicare PIN
CO01220813Medicaid