Provider Demographics
NPI:1366470353
Name:GREYDANUS, WESLEY K (MD)
Entity Type:Individual
Prefix:DR
First Name:WESLEY
Middle Name:K
Last Name:GREYDANUS
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 2408
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78298-2408
Mailing Address - Country:US
Mailing Address - Phone:210-485-1850
Mailing Address - Fax:210-493-9500
Practice Address - Street 1:16607 BLANCO RD
Practice Address - Street 2:SUITE #603
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-1941
Practice Address - Country:US
Practice Address - Phone:210-485-1850
Practice Address - Fax:210-493-9500
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2009-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00024790207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GR3666OtherB/S REGENCE 90
WA1037654Medicaid
50101OtherL&I
WA1037654Medicaid
50101OtherL&I
050085728Medicare ID - Type UnspecifiedRR