Provider Demographics
NPI:1922437391
Name:WARDAK, KHALIL
Entity Type:Individual
Prefix:
First Name:KHALIL
Middle Name:
Last Name:WARDAK
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 1:591 HONEYSUCKLE LN
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33327-2418
Mailing Address - Country:US
Mailing Address - Phone:954-357-5214
Mailing Address - Fax:954-327-6580
Practice Address - Street 1:5301 SW 31ST AVE
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-6906
Practice Address - Country:US
Practice Address - Phone:954-357-5214
Practice Address - Fax:954-327-6580
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-06
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMD103643207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology