Provider Demographics
NPI:1417042862
Name:WAKEFIELD, PHILIP MARK (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:MARK
Last Name:WAKEFIELD
Suffix:
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 1:2407 HELTON DR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35630-1067
Mailing Address - Country:US
Mailing Address - Phone:256-718-5900
Mailing Address - Fax:256-718-5918
Practice Address - Street 1:2407 HELTON DR
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-1067
Practice Address - Country:US
Practice Address - Phone:256-718-5900
Practice Address - Fax:256-718-5918
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12686207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51015991OtherBLUE CROSS BLUE SHIELD
AL000015991Medicaid
000015991Medicare ID - Type Unspecified
AL51015991OtherBLUE CROSS BLUE SHIELD