Provider Demographics
NPI:1366595704
Name:SERIN, WAYNE RICHARD (OD)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:RICHARD
Last Name:SERIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 OLD TOWNE DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-6140
Mailing Address - Country:US
Mailing Address - Phone:714-349-5086
Mailing Address - Fax:
Practice Address - Street 1:100 LEGACY POINTE BLVD
Practice Address - Street 2:
Practice Address - City:MOUNT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-2497
Practice Address - Country:US
Practice Address - Phone:615-583-4495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3791152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAT87231Medicare UPIN