Provider Demographics
NPI:1629294020
Name:J W PODIATRY PC
Entity Type:Organization
Organization Name:J W PODIATRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:W
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:WAKIM
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:508-586-4444
Mailing Address - Street 1:22 CHRISTY DR
Mailing Address - Street 2:5
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-1839
Mailing Address - Country:US
Mailing Address - Phone:508-586-4444
Mailing Address - Fax:508-586-4449
Practice Address - Street 1:22 CHRISTY DR
Practice Address - Street 2:5
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-1839
Practice Address - Country:US
Practice Address - Phone:508-586-4444
Practice Address - Fax:508-586-4449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY78012Medicare ID - Type Unspecified
4004360001Medicare NSC