Provider Demographics
NPI:1558579201
Name:WAKEFIELD MEDICAL PROFESSIONALS, P.C.
Entity Type:Organization
Organization Name:WAKEFIELD MEDICAL PROFESSIONALS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RODOLFO
Authorized Official - Middle Name:COMUYOG
Authorized Official - Last Name:UY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-994-6755
Mailing Address - Street 1:711 NEREID AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10466-1201
Mailing Address - Country:US
Mailing Address - Phone:718-994-6755
Mailing Address - Fax:718-994-3032
Practice Address - Street 1:711 NEREID AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10466-1201
Practice Address - Country:US
Practice Address - Phone:718-994-6755
Practice Address - Fax:718-994-3032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY236741207Q00000X
NY202436207R00000X
NY237144207R00000X
NY166745208000000X
NY170475208000000X
NY218147208000000X
NY169367208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00968790Medicaid
NYA64220Medicare UPIN
NY500Z51Medicare ID - Type Unspecified