Provider Demographics
NPI:1063497337
Name:WAKEFIELD, GEORGE H III (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:H
Last Name:WAKEFIELD
Suffix:III
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 1:1825 PARK PL
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-1149
Mailing Address - Country:US
Mailing Address - Phone:334-293-8747
Mailing Address - Fax:334-834-2185
Practice Address - Street 1:1825 PARK PL
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-1149
Practice Address - Country:US
Practice Address - Phone:334-293-8747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-09
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL000137332085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009926595Medicaid
E57522Medicare UPIN
AL009926595Medicaid