Provider Demographics
NPI:1992834295
Name:WAKEHAM, KEVIN M (DPM)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:M
Last Name:WAKEHAM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:767 BOSTON POST RD
Mailing Address - Street 2:
Mailing Address - City:OLD SAYBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06475-2127
Mailing Address - Country:US
Mailing Address - Phone:860-388-2641
Mailing Address - Fax:860-395-2928
Practice Address - Street 1:767 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:OLD SAYBROOK
Practice Address - State:CT
Practice Address - Zip Code:06475-2127
Practice Address - Country:US
Practice Address - Phone:860-388-2641
Practice Address - Fax:860-395-2928
Is Sole Proprietor?:No
Enumeration Date:2007-03-04
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000317213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T22471Medicare UPIN