Basic Information
| Provider Information | |||||||||
| NPI: | 1710931464 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAKIL | ||||||||
| FirstName: | FRED | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4 | ||||||||
| Address2: | |||||||||
| City: | MAD RIVER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955520004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074965688 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 500 B STREET SUITE B | ||||||||
| Address2: | |||||||||
| City: | SCOTIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95565 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7077645617 | ||||||||
| FaxNumber: | 7077645618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 11/05/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 11/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | G49172 | CA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207Q00000X | G49172 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | CA370807 | 05 | CA | MEDICAID |