Healthcare Provider Details

I. General information

NPI: 1689695371
Provider Name (Legal Business Name): WAJID A KHUDDUS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 10/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6711 MILLHOPPER RD
GAINESVILLE FL
32653-3944
US

IV. Provider business mailing address

PO BOX 141450
GAINESVILLE FL
32614-1450
US

V. Phone/Fax

Practice location:
  • Phone: 352-367-9700
  • Fax: 352-367-1009
Mailing address:
  • Phone: 352-367-9700
  • Fax: 352-367-1009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME93049
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: