Provider Demographics
NPI:1497738330
Name:WAKIM, W ANTHONY (DPM)
Entity Type:Individual
Prefix:
First Name:W
Middle Name:ANTHONY
Last Name:WAKIM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:RAYNHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02767
Mailing Address - Country:US
Mailing Address - Phone:508-894-0400
Mailing Address - Fax:508-559-7035
Practice Address - Street 1:31 ROCHE BROTHERS WAY
Practice Address - Street 2:TWP, SUITE 140
Practice Address - City:N EASTON
Practice Address - State:MA
Practice Address - Zip Code:02767
Practice Address - Country:US
Practice Address - Phone:508-894-0400
Practice Address - Fax:508-894-0332
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2017-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1715213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0361291Medicaid
MAY7078802Medicare PIN
T58764Medicare UPIN