Provider Demographics
NPI:1174563092
Name:WAXMAN, DAVID L (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:L
Last Name:WAXMAN
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 1:527 MEDICAL PARK DR STE 400
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-9010
Mailing Address - Country:US
Mailing Address - Phone:681-342-3550
Mailing Address - Fax:681-342-3507
Practice Address - Street 1:527 MEDICAL PARK DR STE 400
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-9010
Practice Address - Country:US
Practice Address - Phone:681-342-3550
Practice Address - Fax:681-342-3507
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV14240207X00000X, 207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVWV2679AOtherMEDICARE PTAN
WV0097123000Medicaid
1362317OtherUMWA
200004627OtherRAILROAD MEDICARE
001720802OtherBLUE CROSS
WV14240BOtherHEALTH PLAN OHIO VALLEY
WVWV2679AOtherMEDICARE PTAN
WV0097123000Medicaid