Provider Demographics
NPI:1417051509
Name:WAYNE, AUDREY L (MD)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:L
Last Name:WAYNE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 SALT CREEK LANE
Mailing Address - Street 2:STE 100
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521
Mailing Address - Country:US
Mailing Address - Phone:630-654-4551
Mailing Address - Fax:630-654-0498
Practice Address - Street 1:12 SALT CREEK LANE
Practice Address - Street 2:STE 100
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521
Practice Address - Country:US
Practice Address - Phone:630-654-4551
Practice Address - Fax:630-654-0498
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36060060207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0220130801OtherBLUE CROSS BLUE SHIELD
36060060OtherIL LICENSE
D14317Medicare UPIN
IL0220130801OtherBLUE CROSS BLUE SHIELD