Basic Information
| Provider Information | |||||||||
| NPI: | 1497738330 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAKIM | ||||||||
| FirstName: | W | ||||||||
| MiddleName: | ANTHONY | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1215 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | RAYNHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088940400 | ||||||||
| FaxNumber: | 5085597035 | ||||||||
| Practice Location | |||||||||
| Address1: | 31 ROCHE BROTHERS WAY | ||||||||
| Address2: | TWP, SUITE 140 | ||||||||
| City: | N EASTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088940400 | ||||||||
| FaxNumber: | 5088940332 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2005 | ||||||||
| LastUpdateDate: | 09/25/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 1715 | MA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 0361291 | 05 | MA | MEDICAID |