Basic Information
| Provider Information | |||||||||
| NPI: | 1649462243 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAKAMATSU | ||||||||
| FirstName: | MICAH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3000 COLBY ST | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947052083 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3000 COLBY ST | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947052083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5106660854 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2007 | ||||||||
| LastUpdateDate: | 11/14/2018 | ||||||||
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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 | 207L00000X | A95654 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.