Provider Demographics
NPI:1407867708
Name:WAKEFIELD, ANDREW ERVIN (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:ERVIN
Last Name:WAKEFIELD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:360 BLOOMFIELD AVE
Mailing Address - Street 2:SUITE 209
Mailing Address - City:WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06095-2700
Mailing Address - Country:US
Mailing Address - Phone:860-688-1311
Mailing Address - Fax:860-687-1319
Practice Address - Street 1:360 BLOOMFIELD AVE
Practice Address - Street 2:SUITE 209
Practice Address - City:WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06095-2700
Practice Address - Country:US
Practice Address - Phone:860-688-1311
Practice Address - Fax:860-687-1319
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT037617207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001376179Medicaid
G90469Medicare UPIN
140000203Medicare ID - Type Unspecified