Basic Information
| Provider Information | |||||||||
| NPI: | 1215151543 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAKEFIELD | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | BRENT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | II | ||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WAKEFIELD | ||||||||
| OtherFirstName: | C. | ||||||||
| OtherMiddleName: | BRENT | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | II | ||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 8577 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681080577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023977989 | ||||||||
| FaxNumber: | 4023978703 | ||||||||
| Practice Location | |||||||||
| Address1: | 10707 PACIFIC ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681144762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023977989 | ||||||||
| FaxNumber: | 4023937554 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2007 | ||||||||
| LastUpdateDate: | 04/01/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 5286 | NE | Y | Allopathic & Osteopathic Physicians | Urology |
No ID Information.