Provider Demographics
NPI:1215151543
Name:WAKEFIELD, CHARLES BRENT II (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:BRENT
Last Name:WAKEFIELD
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:C.
Other - Middle Name:BRENT
Other - Last Name:WAKEFIELD
Other - Suffix:II
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 8577
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68108-0577
Mailing Address - Country:US
Mailing Address - Phone:402-397-7989
Mailing Address - Fax:402-397-8703
Practice Address - Street 1:10707 PACIFIC ST
Practice Address - Street 2:SUITE 101
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-4762
Practice Address - Country:US
Practice Address - Phone:402-397-7989
Practice Address - Fax:402-393-7554
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE5286208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology