Provider Demographics
NPI:1205099959
Name:WAKIM, JAD JOSEPH (MD)
Entity type:Individual
Prefix:DR
First Name:JAD
Middle Name:JOSEPH
Last Name:WAKIM
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 1:1180 COLLEGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901
Mailing Address - Country:US
Mailing Address - Phone:307-382-2234
Mailing Address - Fax:307-382-2302
Practice Address - Street 1:1180 COLLEGE DRIVE
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901
Practice Address - Country:US
Practice Address - Phone:307-382-2234
Practice Address - Fax:307-382-2302
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN3381207RH0003X
WY8962A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY133851000Medicaid