Provider Demographics
NPI:1629017165
Name:WAKEFIELD, WILLIAM M (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:M
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 1:6355 S BUFFALO DR FL 3
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-2133
Mailing Address - Country:US
Mailing Address - Phone:702-216-3346
Mailing Address - Fax:702-671-6883
Practice Address - Street 1:6170 N DURANGO DR STE 130
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89149-3923
Practice Address - Country:US
Practice Address - Phone:702-940-1550
Practice Address - Fax:702-940-1551
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA84209207Q00000X
WAMD00036020207Q00000X
NV10042207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A842090Medicaid
NV10042OtherSTATE LICENSE
NV1629017165Medicaid