Provider Demographics
NPI:1487831046
Name:WAYNE S. GRADMAN, MD INC
Entity Type:Organization
Organization Name:WAYNE S. GRADMAN, MD INC
Other - Org Name:BEVERLY HILLS VEINS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:STUART
Authorized Official - Last Name:GRADMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-277-4868
Mailing Address - Street 1:2080 CENTURY PARK E
Mailing Address - Street 2:SUITE #803
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90067-2001
Mailing Address - Country:US
Mailing Address - Phone:310-277-4868
Mailing Address - Fax:310-277-4869
Practice Address - Street 1:2080 CENTURY PARK E
Practice Address - Street 2:SUITE #803
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90067-2001
Practice Address - Country:US
Practice Address - Phone:310-277-4868
Practice Address - Fax:310-277-4869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-25
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG176962086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0040310Medicaid
CAW10694Medicare PIN