Provider Demographics
NPI:1336115799
Name:OLD, WAYNE D (MD)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:D
Last Name:OLD
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:PO BOX 7068
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-0068
Mailing Address - Country:US
Mailing Address - Phone:757-686-3508
Mailing Address - Fax:757-686-0541
Practice Address - Street 1:612 KINGSBOROUGH SQ
Practice Address - Street 2:SUITE 100
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-5041
Practice Address - Country:US
Practice Address - Phone:757-547-9294
Practice Address - Fax:757-213-9374
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101035590207RC0000X, 207RI0011X
VA0101035591207RA0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0001XAllopathic & Osteopathic PhysiciansInternal MedicineAdvanced Heart Failure and Transplant Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006010393Medicaid
VAPAROtherVHN/PHCS
VAPAROtherFIRST HEALTH COMMERCIAL/SOUTHERN HEALTH/COVENTRY
VA-001OtherCHAMPUS/TRICARE
NC0570ROtherBC/BS NC
VA15071OtherOPTIMA/SENTARA
VA006059066Medicaid
VA250366OtherATHEM BC/BS VA/HK
VA259544OtherANTHEM BCBS
VAPAROtherVPH
NC890570RMedicaid
VAPAROtherMID-ATLANTIC VICARE
VAPAROtherUSA MANAGED CARE
VA263654OtherUHC/MAMSI/MDIPA
VA75288OtherSENTARA OHP/SHP
VAPAROtherCORVEL/CORCARE
VAPAROtherCIGNA
VAPAROtherAETNA PPO
VAPAROtherMULTIPLAN
VA006010393Medicaid
VA110038316Medicare PIN
VAPAROtherVHN/PHCS
NC2021848Medicare PIN
NC0570ROtherBC/BS NC
VA006059066Medicaid