Healthcare Provider Details

I. General information

NPI: 1699863258
Provider Name (Legal Business Name): ROBERT E WAILES MD A PROFESSIONAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 09/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3998 VISTA WAY STE C106
OCEANSIDE CA
92056-4500
US

IV. Provider business mailing address

477 N. EL CAMINO REAL STE B301
ENCINITAS CA
92024
US

V. Phone/Fax

Practice location:
  • Phone: 760-941-2600
  • Fax: 760-941-4814
Mailing address:
  • Phone: 760-753-1104
  • Fax: 760-943-6494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROBERT EUGENE WAILES
Title or Position: CEO
Credential: M.D.
Phone: 760-753-1104