Provider Demographics
NPI:1669458600
Name:WAKEMAN, PETER J (DC)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:J
Last Name:WAKEMAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 MEMORIAL MEDICAL PKWY STE 305
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-5169
Mailing Address - Country:US
Mailing Address - Phone:386-673-0201
Mailing Address - Fax:386-677-8143
Practice Address - Street 1:305 MEMORIAL MEDICAL PKWY STE 305
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5169
Practice Address - Country:US
Practice Address - Phone:386-673-0201
Practice Address - Fax:386-677-8143
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-21
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH5831111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL22266OtherBCBS
FL050602800Medicaid
FLP00103322OtherRAILROAD MEDICARE PIN
FLP00103322OtherRAILROAD MEDICARE PIN
FLT84318Medicare UPIN
FL22266Medicare ID - Type Unspecified
6487700001Medicare NSC