Provider Demographics
NPI:1982661088
Name:WAKE, ROBERT W (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:WAKE
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 1:877 JEFFERSON AVE
Mailing Address - Street 2:ATTN: PROVIDER ENROLLMENT
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-2807
Mailing Address - Country:US
Mailing Address - Phone:901-545-7302
Mailing Address - Fax:
Practice Address - Street 1:6555 QUINCE RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-8202
Practice Address - Country:US
Practice Address - Phone:901-515-5704
Practice Address - Fax:901-515-5729
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN17572208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP01245913OtherRAILROAD MEDICARE
AR117837001Medicaid
TNQ002427Medicaid
MS00010307Medicaid
TN4355718OtherBCBS
MS00010307Medicaid
TN4355718OtherBCBS