Provider Demographics
NPI:1154362630
Name:WAILES, ROBERT EUGENE (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:EUGENE
Last Name:WAILES
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 1:477 N. EL CAMINO REAL STE B301
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024
Mailing Address - Country:US
Mailing Address - Phone:760-753-1104
Mailing Address - Fax:760-943-6494
Practice Address - Street 1:3998 VISTA WAY # C-108
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-4500
Practice Address - Country:US
Practice Address - Phone:760-753-1104
Practice Address - Fax:760-943-6494
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG47938174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG47938CMedicare PIN
CAA50870Medicare UPIN