Healthcare Provider Details

I. General information

NPI: 1831131101
Provider Name (Legal Business Name): WAK S CHIA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1702 VAUGHN RD
WOOD RIVER IL
62095-1898
US

IV. Provider business mailing address

1702 VAUGHN RD
WOOD RIVER IL
62095-1898
US

V. Phone/Fax

Practice location:
  • Phone: 618-259-5100
  • Fax: 618-259-3101
Mailing address:
  • Phone: 618-259-5100
  • Fax: 618-259-3101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: