Provider Demographics
NPI:1023190915
Name:WAKEFIELD PEDIATRICS & ADOLESCENT MEDICINE,P.A.
Entity Type:Organization
Organization Name:WAKEFIELD PEDIATRICS & ADOLESCENT MEDICINE,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MILTON-JESUS
Authorized Official - Middle Name:CABALONA
Authorized Official - Last Name:SEVILLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-570-7010
Mailing Address - Street 1:14341 NEW FALLS OF NEUSE
Mailing Address - Street 2:SUITE 122
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27614-8292
Mailing Address - Country:US
Mailing Address - Phone:919-570-7010
Mailing Address - Fax:919-570-7020
Practice Address - Street 1:14341 NEW FALLS OF NEUSE
Practice Address - Street 2:SUITE 122
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27614-8292
Practice Address - Country:US
Practice Address - Phone:919-570-7010
Practice Address - Fax:919-570-7020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89130T6Medicaid