Provider Demographics
NPI:1790750230
Name:PRETILA, WAYNE C (MD)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:C
Last Name:PRETILA
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 1:1451 N GARDNER ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47170-7751
Mailing Address - Country:US
Mailing Address - Phone:812-752-3456
Mailing Address - Fax:812-752-5884
Practice Address - Street 1:425 LEWIS HARGETT CIR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-3590
Practice Address - Country:US
Practice Address - Phone:859-268-1030
Practice Address - Fax:859-269-4120
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01026839A207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN940540UUOtherLEGACY MEDICARE
IN100221310Medicaid
IN100221310Medicaid
IN940540UUOtherLEGACY MEDICARE