Healthcare Provider Details

I. General information

NPI: 1407013527
Provider Name (Legal Business Name): ADAM WELLIKOFF
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2008
Last Update Date: 02/26/2020
Certification Date: 02/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 S CONGRESS AVE STE 204
ATLANTIS FL
33462-6635
US

IV. Provider business mailing address

5401 S CONGRESS AVE STE 204
LAKE WORTH FL
33462-6637
US

V. Phone/Fax

Practice location:
  • Phone: 561-967-4118
  • Fax:
Mailing address:
  • Phone: 561-967-4118
  • Fax: 561-967-3463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberME124151
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: