Provider Demographics
NPI:1043507031
Name:KHALIL, WAGDY A
Entity Type:Individual
Prefix:
First Name:WAGDY
Middle Name:A
Last Name:KHALIL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:817 WHITING AVE
Mailing Address - Street 2:
Mailing Address - City:STEVENS POINT
Mailing Address - State:WI
Mailing Address - Zip Code:54481-5246
Mailing Address - Country:US
Mailing Address - Phone:715-345-5350
Mailing Address - Fax:715-345-5966
Practice Address - Street 1:817 WHITING AVE
Practice Address - Street 2:
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54481
Practice Address - Country:US
Practice Address - Phone:715-345-5350
Practice Address - Fax:715-345-5966
Is Sole Proprietor?:No
Enumeration Date:2011-06-29
Last Update Date:2022-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI60427-202084P0800X
FLME1295982084P0800X
IA455032084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry