Provider Demographics
NPI:1811005192
Name:TAMAKLO, WILBERFORCE (MD)
Entity Type:Individual
Prefix:
First Name:WILBERFORCE
Middle Name:
Last Name:TAMAKLO
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 1:109 ESSEX DR
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-3318
Mailing Address - Country:US
Mailing Address - Phone:864-512-3879
Mailing Address - Fax:864-512-3848
Practice Address - Street 1:800 N FANT ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-5708
Practice Address - Country:US
Practice Address - Phone:864-512-1810
Practice Address - Fax:864-512-1805
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC276962084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC276962Medicaid
SC276962Medicaid
SCE53384Medicare UPIN