Healthcare Provider Details

I. General information

NPI: 1386635217
Provider Name (Legal Business Name): JOHN KEENE WAKELIN III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5005 ARLINGTON CENTRE BLVD
COLUMBUS OH
43220-2912
US

IV. Provider business mailing address

5005 ARLINGTON CENTRE BLVD
COLUMBUS OH
43220-2912
US

V. Phone/Fax

Practice location:
  • Phone: 614-246-6900
  • Fax: 614-246-6909
Mailing address:
  • Phone: 614-246-6900
  • Fax: 614-246-6909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number35 08 0290 W
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: