1093033789 NPI number — DR. RYAN JOHN WAKIM M.D.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093033789 NPI number — DR. RYAN JOHN WAKIM M.D.

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

WAKIM

Provider First Name:

RYAN

Provider Middle Name:

JOHN

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

M.D.

Provider Gender Code:

M

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1093033789

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

09/17/2025

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

1005 WHITE WILLOW WAY

Provider Second Line Business Mailing Address:

ATTN: RACHEL DETEC

Provider Business Mailing Address City Name:

MORGANTOWN

Provider Business Mailing Address State Name:

WV

Provider Business Mailing Address Postal Code:

26505-6119

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

304-280-7337

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

1100 MAIN ST STE 104

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

WHEELING

Provider Business Practice Location Address State Name:

WV

Provider Business Practice Location Address Postal Code:

26003-2737

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

304-460-5123

Provider Business Practice Location Address Fax Number:

888-276-3121

Provider Enumeration Date:

05/05/2010

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 2084P0800X , with the licence number:  D0090198 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2084P0800X , with the licence number: 52407 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2084P0800X , with the licence number: DR.0064121 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
• Taxonomy code: 2084P0800X , with the licence number: 69641 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2084P0800X , with the licence number: ME143130 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2084P0800X , with the licence number: MD458987 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2084P0800X , with the licence number: 21739 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2084P0800X , with the licence number: 41470 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2084P0800X , with the licence number: 036156879 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2084P0800X , with the licence number: 84710 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2084P0800X , with the licence number: 35.136307 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2084P0800X , with the licence number: 24727 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2084P0800X , with the licence number: 303652 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2084P0800X , with the licence number: 53466 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

• Identifier: 338366 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
• Identifier: MD458987 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 21739 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
• Identifier: 290330 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
• Identifier: 35.136307 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 66653 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
• Identifier: 71258 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: C1-0024502 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
• Identifier: 303652 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
• Identifier: 52407 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
• Identifier: 0101276200 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
• Identifier: MD210001486 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
• Identifier: T1594 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 24727 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
• Identifier: 25MA11289500 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
• Identifier: 53466 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
• Identifier: 84710 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
• Identifier: MD.61293790 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
• Identifier: ME143130 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 41470 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".