Provider Demographics
NPI:1508833930
Name:WASTEK, GREGORY J (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:J
Last Name:WASTEK
Suffix:
Gender:M
Credentials:MD, PHD
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 12060
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89112-0060
Mailing Address - Country:US
Mailing Address - Phone:702-853-7451
Mailing Address - Fax:909-557-1924
Practice Address - Street 1:6850 N DURANGO DR
Practice Address - Street 2:SUITE 100
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89149-4595
Practice Address - Country:US
Practice Address - Phone:702-589-3100
Practice Address - Fax:702-851-7725
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-03
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6905207N00000X, 207ND0101X, 207NP0225X, 207NS0135X
CAG59991207N00000X, 207ND0101X, 207NS0135X
CAG55591207NP0225X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV070014199OtherRAILROAD MEDICARE
NV2019476Medicaid
NVE47414Medicare UPIN
NVGO532ZMedicare PIN
NVNV6905Medicare PIN
NVV32893Medicare PIN