Provider Demographics
NPI:1447334206
Name:WAKEFIELD, BRENT ALAN (MD)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:ALAN
Last Name:WAKEFIELD
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 1:615 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-4138
Mailing Address - Country:US
Mailing Address - Phone:918-299-8080
Mailing Address - Fax:918-298-2838
Practice Address - Street 1:615 E MAIN ST
Practice Address - Street 2:
Practice Address - City:JENKS
Practice Address - State:OK
Practice Address - Zip Code:74037-4138
Practice Address - Country:US
Practice Address - Phone:918-299-8080
Practice Address - Fax:918-298-2838
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK22988207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK441911615001OtherBLUECROSS BLUESHIELD
OK7837678OtherAETNA
OK441911615001OtherBLUECROSS BLUESHIELD