Provider Demographics
NPI:1306959754
Name:AUSTIN, WAYNE DWIGHT (MD)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:DWIGHT
Last Name:AUSTIN
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:PO BOX 1761
Mailing Address - Street 2:260 NORTH BROAD STREET
Mailing Address - City:WINDER
Mailing Address - State:GA
Mailing Address - Zip Code:30680-6761
Mailing Address - Country:US
Mailing Address - Phone:770-867-9800
Mailing Address - Fax:770-868-4569
Practice Address - Street 1:260 N BROAD ST
Practice Address - Street 2:
Practice Address - City:WINDER
Practice Address - State:GA
Practice Address - Zip Code:30680-2180
Practice Address - Country:US
Practice Address - Phone:770-867-9800
Practice Address - Fax:770-868-4569
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207R00000X207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000228555CMedicaid
GA235579OtherBLUE CROSS/BLUE SHIELD
GA235579OtherBLUE CROSS/BLUE SHIELD