Healthcare Provider Details

I. General information

NPI: 1073684551
Provider Name (Legal Business Name): PAUL WIGODA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1404 E BROWARD BLVD
FORT LAUDERDALE FL
33301-2138
US

IV. Provider business mailing address

1404 E BROWARD BLVD
FORT LAUDERDALE FL
33301-2138
US

V. Phone/Fax

Practice location:
  • Phone: 954-463-7088
  • Fax: 954-463-8766
Mailing address:
  • Phone: 954-463-7088
  • Fax: 954-463-8766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberME0076810
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: