MEDICARE: KHALIL WARDAK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ZP0101X	Anatomic Pathology Physician	MD103643	FL

General Provider Information

NPI Number	:	1922437391
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KHALIL WARDAK

Provider Business Mailing Address
First Line	:	591 HONEYSUCKLE LN
Second Line	:
City	:	WESTON
State	:	FL
Zip	:	33327-2418
Country	:	US
Telephone Number	:	954-357-5214
Fax Number	:	954-327-6580

Provider Business Practice Location Address
First Line	:	5301 SW 31ST AVE
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33312-6906
Country	:	US
Telephone Number	:	954-357-5214
Fax Number	:	954-327-6580

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/06/2013
Last Update Date	:	11/06/2013

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