Basic Information
| Provider Information | |||||||||
| NPI: | 1538128137 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WACKSMAN | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6804 CECELIA DR | ||||||||
| Address2: | |||||||||
| City: | NEW PORT RICHEY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346534935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7272320644 | ||||||||
| FaxNumber: | 8885460488 | ||||||||
| Practice Location | |||||||||
| Address1: | 6804 CECELIA DR | ||||||||
| Address2: | |||||||||
| City: | NEW PORT RICHEY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346534935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7272320644 | ||||||||
| FaxNumber: | 8885460488 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2006 | ||||||||
| LastUpdateDate: | 02/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD035846E | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RH0002X | ME0086161 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine | 207RH0002X | 35.135520 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine | 207R00000X | ME0086161 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 007234300 | 05 | FL | MEDICAID |