Provider Demographics
NPI:1679663777
Name:WAKEMAN, GREGORY LANCE (DO)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:LANCE
Last Name:WAKEMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6971 EL CAMINO REAL
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92009
Mailing Address - Country:US
Mailing Address - Phone:760-603-3221
Mailing Address - Fax:760-603-7719
Practice Address - Street 1:6971 EL CAMINO REAL
Practice Address - Street 2:SUITE 101
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92009
Practice Address - Country:US
Practice Address - Phone:760-603-3221
Practice Address - Fax:760-603-7719
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA20A6797207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
20A6797Medicare PIN
G46485Medicare UPIN