Healthcare Provider Details

I. General information

NPI: 1366541997
Provider Name (Legal Business Name): WAHBA W WAHBA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 07/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 WILDWOOD ST SUITE 1
DAYTONA BEACH FL
32117-4568
US

IV. Provider business mailing address

810 WILDWOOD ST SUITE 1
DAYTONA BEACH FL
32117-4568
US

V. Phone/Fax

Practice location:
  • Phone: 386-258-7100
  • Fax: 386-253-1843
Mailing address:
  • Phone: 386-258-7100
  • Fax: 386-253-1843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License NumberME42004
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberME42004
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberME42004
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: