Provider Demographics
NPI:1689695876
Name:VAYNER, OLEG A
Entity Type:Individual
Prefix:
First Name:OLEG
Middle Name:A
Last Name:VAYNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10681 LABURNHAM CIR
Mailing Address - Street 2:
Mailing Address - City:TRUCKEE
Mailing Address - State:CA
Mailing Address - Zip Code:96161-1316
Mailing Address - Country:US
Mailing Address - Phone:917-974-9458
Mailing Address - Fax:
Practice Address - Street 1:10956 DONNER PASS RD
Practice Address - Street 2:STE 130
Practice Address - City:TRUCKEE
Practice Address - State:CA
Practice Address - Zip Code:96161-4861
Practice Address - Country:US
Practice Address - Phone:530-587-3523
Practice Address - Fax:530-587-1004
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY232883-1208000000X
CAC55496208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02585284Medicaid