Provider Demographics
NPI:1497782189
Name:WALTZER, WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:
Last Name:WALTZER
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 1559
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-0989
Mailing Address - Country:US
Mailing Address - Phone:631-444-6270
Mailing Address - Fax:
Practice Address - Street 1:24 RESEARCH WAY
Practice Address - Street 2:SUITE 500
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-3453
Practice Address - Country:US
Practice Address - Phone:631-444-6270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY139086208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00496066Medicaid
NY0388S2OtherEMPIRE B/C B/S
NY4401701OtherAETNA
NY30A391Medicare ID - Type Unspecified
NY0388S2OtherEMPIRE B/C B/S