Provider Demographics
NPI:1255351599
Name:WALLIZADA, FATAH ABDUL (MD)
Entity type:Individual
Prefix:DR
First Name:FATAH
Middle Name:ABDUL
Last Name:WALLIZADA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1395 CASSAT AVE
Mailing Address - Street 2:SUITE# 1
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32205-9616
Mailing Address - Country:US
Mailing Address - Phone:904-388-5832
Mailing Address - Fax:904-388-6270
Practice Address - Street 1:1395 CASSAT AVE
Practice Address - Street 2:SUITE# 1
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32205-9616
Practice Address - Country:US
Practice Address - Phone:904-388-5832
Practice Address - Fax:904-388-6270
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0062087208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL371234600Medicaid