Provider Demographics
NPI:1093033789
Name:WAKIM, RYAN JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:JOHN
Last Name:WAKIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1005 WHITE WILLOW WAY
Mailing Address - Street 2:ATTN: RACHEL DETEC
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-6119
Mailing Address - Country:US
Mailing Address - Phone:304-280-7337
Mailing Address - Fax:800-734-8498
Practice Address - Street 1:1100 MAIN ST STE 104
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-2737
Practice Address - Country:US
Practice Address - Phone:304-460-5123
Practice Address - Fax:800-734-8498
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-05
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.00641212084P0800X
OH35.1363072084P0800X
IL0361568792084P0800X
FLME1431302084P0800X
NY3036522084P0800X
KY534662084P0800X
GA847102084P0800X
CT696412084P0800X
SC524072084P0800X
MDD00901982084P0800X
AL414702084P0800X
WV247272084P0800X
PAMD4589872084P0800X
NH217392084P0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036156879OtherMEDICAL LICENSE
MA290330OtherMEDICAL LICENSE
KY53466OtherMEDICAL LICENSE
RIMD17998OtherMEDICAL LICENSE
OH35.136307OtherMEDICAL LICENSE
AZ66653OtherMEDICAL LICENSE
WAMD.61293790OtherMEDICAL LICENSE
NH21739OtherMEDICAL LICENSE
AL41470OtherMEDICAL LICENSE
CO0064121OtherMEDICAL LICENSE
VA0101276200OtherMEDICAL LICENSE
NY303652OtherMEDICAL LICENSE
LA338366OtherMEDICAL LICENSE
CT69641OtherMEDICAL LICENSE
FLME143130OtherMEDICAL LICENSE
MN71258OtherMEDICAL LICENSE
DCMD210001486OtherMEDICAL LICENSE
TXT1594OtherMEDICAL LICENSE
NJ25MA11289500OtherMEDICAL LICENSE
SC52407OtherMEDICAL LICENSE
GA84710OtherMEDICAL LICENSE
DEC1-0024502OtherMEDICAL LICENSE
WV24727OtherMEDICAL LICENSE
PAMD458987OtherMEDICAL LICENSE