Provider Demographics
NPI:1891776696
Name:WAKEMAN, GARY R (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:R
Last Name:WAKEMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6 PRESERVE WAY
Mailing Address - Street 2:PO BOX 4786
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:12866-5842
Mailing Address - Country:US
Mailing Address - Phone:518-577-8858
Mailing Address - Fax:518-584-8663
Practice Address - Street 1:6 PRESERVE WAY
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866-5842
Practice Address - Country:US
Practice Address - Phone:518-577-8858
Practice Address - Fax:518-584-8663
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY138119207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB07893Medicare UPIN