Provider Demographics
NPI:1659658896
Name:SANJIV WALIA MD PA
Entity Type:Organization
Organization Name:SANJIV WALIA MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SANJIV
Authorized Official - Middle Name:
Authorized Official - Last Name:WALIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-466-1977
Mailing Address - Street 1:2215 NEBRASKA AVE
Mailing Address - Street 2:SUITE 1F2
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950-4864
Mailing Address - Country:US
Mailing Address - Phone:772-466-1977
Mailing Address - Fax:772-466-2433
Practice Address - Street 1:2215 NEBRASKA AVE
Practice Address - Street 2:SUITE 1F2
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-4864
Practice Address - Country:US
Practice Address - Phone:772-466-1977
Practice Address - Fax:772-466-2433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-15
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0042047207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty