Provider Demographics
NPI:1538128137
Name:WACKSMAN, RICHARD M (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:M
Last Name:WACKSMAN
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 1:6804 CECELIA DR
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34653-4935
Mailing Address - Country:US
Mailing Address - Phone:727-232-0644
Mailing Address - Fax:888-546-0488
Practice Address - Street 1:6804 CECELIA DR
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34653-4935
Practice Address - Country:US
Practice Address - Phone:727-232-0644
Practice Address - Fax:888-546-0488
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD035846E207R00000X
FLME0086161207RH0002X, 207R00000X
OH35.135520207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007234300Medicaid
FLE15682Medicare UPIN
PAE15682Medicare UPIN