Provider Demographics
NPI:1790703981
Name:BURGESS, WAYNE CARROLL JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:CARROLL
Last Name:BURGESS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1020 LAKE SUMTER LNDG
Mailing Address - Street 2:
Mailing Address - City:THE VILLAGES
Mailing Address - State:FL
Mailing Address - Zip Code:32162-2699
Mailing Address - Country:US
Mailing Address - Phone:352-674-8905
Mailing Address - Fax:352-674-8901
Practice Address - Street 1:2910 BROWNWOOD BLVD
Practice Address - Street 2:
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32163
Practice Address - Country:US
Practice Address - Phone:352-674-1790
Practice Address - Fax:352-674-8990
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0071102207Q00000X
PAMD051773L207Q00000X
FLME56501207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50062675OtherCAPITAL BC-WMG READYCARE
PA5099039OtherAETNA
MD542984OtherCAREFIRST MD BCBS
PA2161248OtherMAMSI-WMG BIM
PA1544818OtherGATEWAY-WMG
MDP00891595OtherRAIL ROAD MEDICARE
PA030045OtherJOHNS HOPKINS
PA35391OtherGEISINGER
PA001536257Medicaid
PA2161250OtherMAMSI-WMG READYCARE
PA184850OtherUNISON-WMG READYCARE
PA189906OtherUNISON-WMG BIM
PA786092OtherHIGHMARK BLUE SHIELD
MDP01153743OtherRAILROAD MEDICARE
PA20090454OtherAMERIHEALTH MERCY-WMG
PA50062420OtherCAPITAL BC-WMG BIM HOSP
PA20090454OtherAMERIHEALTH MERCY-WMG
PA184850OtherUNISON-WMG READYCARE
PA786092OtherHIGHMARK BLUE SHIELD
PA786092FLTMedicare PIN
MDP01153743OtherRAILROAD MEDICARE
PA2161248OtherMAMSI-WMG BIM
PA786092YEBK-213827Medicare PIN