Provider Demographics
NPI:1437121746
Name:WAYNE, MITCHELL S (DPM)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:S
Last Name:WAYNE
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 1:7001 ORCHARD LAKE RD
Mailing Address - Street 2:SUITE 230B
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3604
Mailing Address - Country:US
Mailing Address - Phone:248-855-3232
Mailing Address - Fax:248-855-3232
Practice Address - Street 1:7001 ORCHARD LAKE RD
Practice Address - Street 2:SUITE 230B
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3604
Practice Address - Country:US
Practice Address - Phone:248-855-3232
Practice Address - Fax:248-855-3232
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901400097213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIT34163OtherHAP
MI000000012402OtherCAPE HEALTH PLAN
MI10105530003OtherWELLNESS PLAN
MI506728OtherCARE CHOICES
MIF37227001Medicare PIN
MI10105530003OtherWELLNESS PLAN
MIN49300001Medicare PIN
MIN49200001Medicare PIN
MI000000012402OtherCAPE HEALTH PLAN
MIT34163Medicare UPIN