Provider Demographics
NPI:1053360669
Name:ABDUL KHALIL WALLIZADA,MD
Entity type:Organization
Organization Name:ABDUL KHALIL WALLIZADA,MD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ABDUL
Authorized Official - Middle Name:KHALIL
Authorized Official - Last Name:WALLIZADA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-276-0005
Mailing Address - Street 1:2140 KINGSLEY AVE
Mailing Address - Street 2:STE.#10
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-5180
Mailing Address - Country:US
Mailing Address - Phone:904-276-0005
Mailing Address - Fax:904-276-9202
Practice Address - Street 1:2140 KINGSLEY AVE
Practice Address - Street 2:STE.#10
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5180
Practice Address - Country:US
Practice Address - Phone:904-276-0005
Practice Address - Fax:904-276-9202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00670262080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL376381100Medicaid
FL25991Medicare ID - Type Unspecified
FL376381100Medicaid