Provider Demographics
NPI:1134656630
Name:ULLAH, WAQAS (MD)
Entity Type:Individual
Prefix:
First Name:WAQAS
Middle Name:
Last Name:ULLAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:FNU
Other - Middle Name:
Other - Last Name:WAQAS ULLAH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2450 W HUNTING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:215-707-2433
Mailing Address - Fax:
Practice Address - Street 1:3401 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5103
Practice Address - Country:US
Practice Address - Phone:215-707-1622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-15
Last Update Date:2021-12-05
Deactivation Date:2017-12-18
Deactivation Code:
Reactivation Date:2018-08-30
Provider Licenses
StateLicense IDTaxonomies
PAMT212511207R00000X
PAMD473810207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine