Healthcare Provider Details

I. General information

NPI: 1598103905
Provider Name (Legal Business Name): WASSEM E FARAGALLA DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2013
Last Update Date: 03/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13600 ICOT BLVD BLDG. B
CLEARWATER FL
33760-3703
US

IV. Provider business mailing address

11416 GRAMERCY PARK AVE
BRADENTON FL
34211-8459
US

V. Phone/Fax

Practice location:
  • Phone: 888-290-6321
  • Fax: 727-669-8417
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO3803
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberPO3803
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: