Provider Demographics
NPI:1396743969
Name:WAKAMATSU, TADAIE (MD)
Entity type:Individual
Prefix:
First Name:TADAIE
Middle Name:
Last Name:WAKAMATSU
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:PO BOX 8157
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19803-8157
Mailing Address - Country:US
Mailing Address - Phone:302-652-6032
Mailing Address - Fax:302-652-6053
Practice Address - Street 1:701 N CLAYTON ST
Practice Address - Street 2:SUITE 601
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19805-3165
Practice Address - Country:US
Practice Address - Phone:302-652-6050
Practice Address - Fax:302-652-6053
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0000899208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000038101Medicaid
DE0000038101Medicaid
B66364Medicare UPIN