Provider Demographics
NPI:1093342594
Name:PAUL, WESLEY
Entity Type:Individual
Prefix:MR
First Name:WESLEY
Middle Name:
Last Name:PAUL
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 1:1809 NE 59TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-2443
Mailing Address - Country:US
Mailing Address - Phone:754-366-7735
Mailing Address - Fax:
Practice Address - Street 1:1809 NE 59TH ST
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-2443
Practice Address - Country:US
Practice Address - Phone:754-366-7735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-25
Last Update Date:2020-04-08
Deactivation Date:2020-03-26
Deactivation Code:
Reactivation Date:2020-04-08
Provider Licenses
StateLicense IDTaxonomies
FL0000208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice