Provider Demographics
NPI:1538380944
Name:MCCORMACK, WAYNE CHARLES (DC)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:CHARLES
Last Name:MCCORMACK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:572 E 28TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210-1434
Mailing Address - Country:US
Mailing Address - Phone:631-953-1995
Mailing Address - Fax:
Practice Address - Street 1:75 N HANGAR RD
Practice Address - Street 2:SUITE 247
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11430-1826
Practice Address - Country:US
Practice Address - Phone:718-656-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX4407-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC04407-5BOtherNYS WORKERS' COMPENSATION BOARD