Provider Demographics
NPI:1568638294
Name:WAKEFIELD, RICHARD
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:
Last Name:WAKEFIELD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2514 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-6776
Mailing Address - Country:US
Mailing Address - Phone:701-746-7000
Mailing Address - Fax:701-746-5220
Practice Address - Street 1:2514 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-6776
Practice Address - Country:US
Practice Address - Phone:701-746-7000
Practice Address - Fax:701-746-5220
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-02
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDH-0063237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN7G771WAOtherBLUE CROSS & BLUE SHIELD
ND57635Medicaid
MN548065500Medicaid
ND24303OtherBLUE CROSS & BLUE SHIELD