Provider Demographics
NPI:1629232368
Name:DEBEATHAM, WAYNE L (MD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:L
Last Name:DEBEATHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3725 BLACKSTONE AVE APT 4G
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-1444
Mailing Address - Country:US
Mailing Address - Phone:860-965-4749
Mailing Address - Fax:888-768-5042
Practice Address - Street 1:701 N BROADWAY
Practice Address - Street 2:
Practice Address - City:SLEEPY HOLLOW
Practice Address - State:NY
Practice Address - Zip Code:10591-1020
Practice Address - Country:US
Practice Address - Phone:914-366-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-11
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY262221208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology