Healthcare Provider Details

I. General information

NPI: 1043507031
Provider Name (Legal Business Name): WAGDY A KHALIL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2011
Last Update Date: 08/26/2025
Certification Date: 08/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 QUARRY PARK RD
MADISON WI
53718-7901
US

IV. Provider business mailing address

817 WHITING AVE
STEVENS POINT WI
54481-5246
US

V. Phone/Fax

Practice location:
  • Phone: 844-767-3769
  • Fax:
Mailing address:
  • Phone: 715-345-5350
  • Fax: 715-345-5966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number60427-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: