Provider Demographics
NPI:1073684551
Name:WIGODA, PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:
Last Name:WIGODA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1404 E BROWARD BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-2138
Mailing Address - Country:US
Mailing Address - Phone:954-463-7088
Mailing Address - Fax:954-463-8766
Practice Address - Street 1:1404 E BROWARD BLVD
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33301-2138
Practice Address - Country:US
Practice Address - Phone:954-463-7088
Practice Address - Fax:954-463-8766
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0076810208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery