Healthcare Provider Details

I. General information

NPI: 1922437391
Provider Name (Legal Business Name): KHALIL WARDAK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2013
Last Update Date: 11/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 SW 31ST AVE
FORT LAUDERDALE FL
33312-6906
US

IV. Provider business mailing address

591 HONEYSUCKLE LN
WESTON FL
33327-2418
US

V. Phone/Fax

Practice location:
  • Phone: 954-357-5214
  • Fax: 954-327-6580
Mailing address:
  • Phone: 954-357-5214
  • Fax: 954-327-6580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License NumberMD103643
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: