Provider Demographics
NPI:1649226291
Name:WAKEFIELD, MARK RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:RICHARD
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:PO BOX 843966
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64184-3966
Mailing Address - Country:US
Mailing Address - Phone:573-884-3300
Mailing Address - Fax:573-884-0943
Practice Address - Street 1:ONE HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65212-0001
Practice Address - Country:US
Practice Address - Phone:573-882-1771
Practice Address - Fax:573-884-7453
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO106072208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00415790OtherRAILROAD MEDICARE
MO209289404Medicaid
MOP00147243OtherRR MEDICARE
MO921425236Medicare PIN
MO921421115Medicare PIN
MO209289404Medicaid