Basic Information
| Provider Information | |||||||||
| NPI: | 1811465719 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ERIC WAKI MD ENT INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2240 N HARBOR BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | FULLERTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928352635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144474100 | ||||||||
| FaxNumber: | 7144471922 | ||||||||
| Practice Location | |||||||||
| Address1: | 2240 N HARBOR BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | FULLERTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928352635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144474100 | ||||||||
| FaxNumber: | 7144471922 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2018 | ||||||||
| LastUpdateDate: | 09/25/2019 | ||||||||
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| AuthorizedOfficialLastName: | WAKI | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
| AuthorizedOfficialMiddleName: | Y | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7144474100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ERIC WAKI MD INC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
No ID Information.