Provider Demographics
NPI:1710931464
Name:WAKIL, FRED W (MD)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:W
Last Name:WAKIL
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 4
Mailing Address - Street 2:
Mailing Address - City:MAD RIVER
Mailing Address - State:CA
Mailing Address - Zip Code:95552-0004
Mailing Address - Country:US
Mailing Address - Phone:707-496-5688
Mailing Address - Fax:
Practice Address - Street 1:500 B STREET SUITE B
Practice Address - Street 2:
Practice Address - City:SCOTIA
Practice Address - State:CA
Practice Address - Zip Code:95565
Practice Address - Country:US
Practice Address - Phone:707-764-5617
Practice Address - Fax:707-764-5618
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG49172207PE0004X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA370807Medicaid
CAAQ150YMedicare PIN