Provider Demographics
NPI:1306855903
Name:WAKNINE, RAPHAEL (MD)
Entity type:Individual
Prefix:
First Name:RAPHAEL
Middle Name:
Last Name:WAKNINE
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 1:120 W 5TH ST
Mailing Address - Street 2:STE 300
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-4641
Mailing Address - Country:US
Mailing Address - Phone:714-834-0757
Mailing Address - Fax:714-834-0848
Practice Address - Street 1:120 W 5TH ST
Practice Address - Street 2:STE 300
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-4641
Practice Address - Country:US
Practice Address - Phone:714-834-0757
Practice Address - Fax:714-834-0848
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA37141174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG77785Medicare UPIN