Provider Demographics
NPI:1699863258
Name:ROBERT E WAILES MD A PROFESSIONAL
Entity type:Organization
Organization Name:ROBERT E WAILES MD A PROFESSIONAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:WAILES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-753-1104
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 STE C106
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:760-941-2600
Practice Address - Fax:760-941-4814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS051203Medicare PIN