Provider Demographics
NPI:1912937822
Name:GILBERTIE, WAYNE J (MD)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:J
Last Name:GILBERTIE
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 1:1350 MAIN ST STE 1007
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01103-1664
Mailing Address - Country:US
Mailing Address - Phone:413-827-7400
Mailing Address - Fax:413-827-7407
Practice Address - Street 1:1350 MAIN ST STE 1007
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01103-1664
Practice Address - Country:US
Practice Address - Phone:413-827-7400
Practice Address - Fax:413-827-7407
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0282652085R0202X
MA1566262085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3199606Medicaid
CT003111789Medicaid
CT300001975Medicare ID - Type Unspecified
CT003111789Medicaid
MA3199606Medicaid