Provider Demographics
NPI:1013938406
Name:ELAM, GARY WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:WAYNE
Last Name:ELAM
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 1:520 N WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-4435
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:520 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4435
Practice Address - Country:US
Practice Address - Phone:432-337-4321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10309207Y00000X
TXE3259207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00R664OtherBC/BS PROVIDER NUMBER
TXB22497Medicare UPIN
TX8500M0Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER