Provider Demographics
NPI:1053398156
Name:WAIT, CALVERT BRYAN (MD)
Entity type:Individual
Prefix:
First Name:CALVERT
Middle Name:BRYAN
Last Name:WAIT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:C.
Other - Middle Name:BRYAN
Other - Last Name:WAIT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:360 N OAK ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46725-1608
Mailing Address - Country:US
Mailing Address - Phone:260-244-0238
Mailing Address - Fax:260-244-1976
Practice Address - Street 1:360 N OAK ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA CITY
Practice Address - State:IN
Practice Address - Zip Code:46725-1608
Practice Address - Country:US
Practice Address - Phone:260-244-0238
Practice Address - Fax:260-244-1976
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-29
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01032361A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN110175692OtherRAILROAD MEDICARE
IN3937240004OtherMEDICARE DMEPOS
IN100263180AMedicaid
IN110175692OtherRAILROAD MEDICARE
B29760Medicare UPIN
IN100263180AMedicaid