Provider Demographics
NPI:1912980079
Name:WIVELL, WAYNE ALBERT (MD)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:ALBERT
Last Name:WIVELL
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 1:6716 NW 11TH PL STE 200
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-4201
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6716 NW 11TH PL STE 200
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-4201
Practice Address - Country:US
Practice Address - Phone:352-331-9729
Practice Address - Fax:352-331-0136
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1451092085R0204X, 2085R0202X
MA819712085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMQ512OtherMEDICARE
FL106807000Medicaid
FLMQ511OtherMEDICARE
FL7CZ1BOtherBCBS