Provider Demographics
NPI:1588826838
Name:WALLIZADA, ABDUL KHALIL (MD)
Entity type:Individual
Prefix:DR
First Name:ABDUL
Middle Name:KHALIL
Last Name:WALLIZADA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:KHALIL
Other - Middle Name:ABDUL
Other - Last Name:WALLIZADA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2051 PROFESSIONAL CENTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4461
Mailing Address - Country:US
Mailing Address - Phone:904-276-0005
Mailing Address - Fax:855-600-3475
Practice Address - Street 1:2051 PROFESSIONAL CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4461
Practice Address - Country:US
Practice Address - Phone:904-276-0005
Practice Address - Fax:855-600-3475
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-27
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME67026208000000X
FLME0067026208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL376381100Medicaid