Healthcare Provider Details

I. General information

NPI: 1588826838
Provider Name (Legal Business Name): ABDUL KHALIL WALLIZADA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: KHALIL ABDUL WALLIZADA MD

II. Dates (important events)

Enumeration Date: 06/27/2008
Last Update Date: 01/10/2025
Certification Date: 01/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2051 PROFESSIONAL CENTER DRIVE
ORANGE PARK FL
32073-4461
US

IV. Provider business mailing address

2051 PROFESSIONAL CENTER DRIVE
ORANGE PARK FL
32073-4461
US

V. Phone/Fax

Practice location:
  • Phone: 904-276-0005
  • Fax: 855-600-3475
Mailing address:
  • Phone: 904-276-0005
  • Fax: 855-600-3475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME67026
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME0067026
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: