Provider Demographics
NPI:1780691949
Name:PAYNE, GARY CHARLES (DPM)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:CHARLES
Last Name:PAYNE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12833B RESEARCH BLVD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78750-3200
Mailing Address - Country:US
Mailing Address - Phone:512-249-2253
Mailing Address - Fax:512-258-2109
Practice Address - Street 1:12833B RESEARCH BLVD.
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78750
Practice Address - Country:US
Practice Address - Phone:512-249-2253
Practice Address - Fax:512-258-2109
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0536213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX018830201Medicaid
11011766OtherAMERIGROUP
4464150001OtherPALMETTO GBA
741891053OtherAETNA
T15205OtherCOMMERCIAL CARRIERS
DPM536OtherCMI WALMART
DPM536OtherAIG
00T800OtherBCBS
480900054OtherUNITED HEALTH CARE RAIL R
741891053OtherAETNA
4464150001Medicare NSC
T15205Medicare UPIN