Provider Demographics
NPI:1679963839
Name:VARDAG, ANWAR M (MD)
Entity type:Individual
Prefix:DR
First Name:ANWAR
Middle Name:M
Last Name:VARDAG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:ANWAR
Other - Middle Name:M
Other - Last Name:VARDAG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:6156 NW 31ST AVE
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33496-3374
Mailing Address - Country:US
Mailing Address - Phone:561-488-8368
Mailing Address - Fax:561-241-2340
Practice Address - Street 1:21644 SR 7
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33428
Practice Address - Country:US
Practice Address - Phone:561-488-8368
Practice Address - Fax:561-488-8376
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-27
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL00617922080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3704441000Medicaid