Healthcare Provider Details

I. General information

NPI: 1053360669
Provider Name (Legal Business Name): ABDUL KHALIL WALLIZADA,MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 07/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2140 KINGSLEY AVE STE.#10
ORANGE PARK FL
32073-5180
US

IV. Provider business mailing address

2140 KINGSLEY AVE STE.#10
ORANGE PARK FL
32073-5180
US

V. Phone/Fax

Practice location:
  • Phone: 904-276-0005
  • Fax: 904-276-9202
Mailing address:
  • Phone: 904-276-0005
  • Fax: 904-276-9202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberME0067026
License Number StateFL

VIII. Authorized Official

Name: DR. ABDUL KHALIL WALLIZADA
Title or Position: OWNER
Credential: MD
Phone: 904-276-0005