Provider Demographics
NPI:1073315925
Name:WAKASA, KODY (MD)
Entity type:Individual
Prefix:
First Name:KODY
Middle Name:
Last Name:WAKASA
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 DARRELL RD
Mailing Address - Street 2:
Mailing Address - City:HILLSBOROUGH
Mailing Address - State:CA
Mailing Address - Zip Code:94010-7109
Mailing Address - Country:US
Mailing Address - Phone:650-787-6234
Mailing Address - Fax:
Practice Address - Street 1:2521 STOCKTON BLVD STE 7200
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2207
Practice Address - Country:US
Practice Address - Phone:916-734-5005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-24
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program