Provider Demographics
NPI:1720030315
Name:WACKYM, PHILLIP ASHLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:ASHLEY
Last Name:WACKYM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:P. ASHLEY
Other - Middle Name:
Other - Last Name:WACKYM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:10 PLUM STREET, 5TH FLOOR
Mailing Address - Street 2:DEPARTMENT OF OTOLARYNGOLOGY-HEAD AND NECK SURGERY
Mailing Address - City:NEW BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08901
Mailing Address - Country:US
Mailing Address - Phone:732-235-5530
Mailing Address - Fax:732-565-9751
Practice Address - Street 1:10 PLUM ST FL 5
Practice Address - Street 2:DEPARTMENT OF OTOLARYNGOLOGY - HEAD AND NECK SURGERY
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-2066
Practice Address - Country:US
Practice Address - Phone:732-235-5530
Practice Address - Fax:732-565-9751
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09934900207YS0123X, 207YX0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & Neurotology
No207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
F29613Medicare UPIN
F29613Medicare UPIN
0059H73601Medicare ID - Type Unspecified
WI32468700Medicaid