Provider Demographics
NPI:1629165279
Name:RUTLEDGE, WAYNE C JR (MD)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:C
Last Name:RUTLEDGE
Suffix:JR
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 1:2605 SANTO DOMINGO DR
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-3057
Mailing Address - Country:US
Mailing Address - Phone:832-594-0987
Mailing Address - Fax:
Practice Address - Street 1:301 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77555-1173
Practice Address - Country:US
Practice Address - Phone:409-772-1425
Practice Address - Fax:409-772-0885
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM1328207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1629165279OtherTRICARE SOUTH
TX151601501Medicaid
TX8BE067OtherBCBSTX
TXP00690098OtherRAILROAD MEDICARE
TX1629165279OtherTRICARE SOUTH
TXP00690098OtherRAILROAD MEDICARE
TX8L8270Medicare PIN
TX322962ZM10Medicare PIN
TX322962YK81Medicare PIN