Provider Demographics
NPI:1265435762
Name:WAKASA, MARC K (MD)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:K
Last Name:WAKASA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:450 STANYAN ST
Mailing Address - Street 2:# 658
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94117-1079
Mailing Address - Country:US
Mailing Address - Phone:415-750-5762
Mailing Address - Fax:415-750-4856
Practice Address - Street 1:450 STANYAN ST
Practice Address - Street 2:# 658
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94117-1079
Practice Address - Country:US
Practice Address - Phone:415-750-5762
Practice Address - Fax:415-750-4856
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2007-07-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG81705208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G817050Medicare ID - Type Unspecified