Provider Demographics
NPI:1609809185
Name:WAIT, CREED LEROY (MD)
Entity Type:Individual
Prefix:
First Name:CREED
Middle Name:LEROY
Last Name:WAIT
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 1:1617 HEMPHILL ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4709
Mailing Address - Country:US
Mailing Address - Phone:817-927-1395
Mailing Address - Fax:
Practice Address - Street 1:1500 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104
Practice Address - Country:US
Practice Address - Phone:817-927-1395
Practice Address - Fax:817-927-3603
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM4632207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR162134001Medicaid
OK200098880AMedicaid
TX183776701Medicaid
AKF33263Medicare UPIN
AR162134001Medicaid