Provider Demographics
NPI:1801994041
Name:WAKEFIELD, CORNELIUS W (MD)
Entity type:Individual
Prefix:
First Name:CORNELIUS
Middle Name:W
Last Name:WAKEFIELD
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 1:5959 GATEWAY BLVD W
Mailing Address - Street 2:# 120
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-3331
Mailing Address - Country:US
Mailing Address - Phone:915-779-1716
Mailing Address - Fax:915-771-6558
Practice Address - Street 1:5959 GATEWAY BLVD W
Practice Address - Street 2:# 120
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-3331
Practice Address - Country:US
Practice Address - Phone:915-779-1716
Practice Address - Fax:915-771-6558
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG1799207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX134813806Medicaid
TX134813809Medicaid
TX8U4608OtherBCBS
TX00U79GOtherBCBS
TXP00311775Medicare PIN
TX00U79GOtherBCBS
TX8G2889Medicare PIN
B27397Medicare UPIN
TX134813809Medicaid