Provider Demographics
NPI:1598103905
Name:FARAGALLA, WASSEM E (DPM)
Entity Type:Individual
Prefix:DR
First Name:WASSEM
Middle Name:E
Last Name:FARAGALLA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11416 GRAMERCY PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34211-8459
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13600 ICOT BLVD
Practice Address - Street 2:BLDG. B
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33760-3703
Practice Address - Country:US
Practice Address - Phone:888-290-6321
Practice Address - Fax:727-669-8417
Is Sole Proprietor?:No
Enumeration Date:2013-06-07
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3803213ES0103X, 213ES0131X
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program