Provider Demographics
NPI:1710931464
Name:WAKIL, FRED W (MD)
Entity type:Individual
Prefix:DR
First Name:FRED
Middle Name:W
Last Name:WAKIL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7
Mailing Address - Street 2:
Mailing Address - City:SCOTIA
Mailing Address - State:CA
Mailing Address - Zip Code:95565-0007
Mailing Address - Country:US
Mailing Address - Phone:707-496-5688
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 7
Practice Address - Street 2:
Practice Address - City:SCOTIA
Practice Address - State:CA
Practice Address - Zip Code:95565-0007
Practice Address - Country:US
Practice Address - Phone:707-764-5617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG49172207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA370807Medicaid
CAAQ150YMedicare PIN