Provider Demographics
NPI:1700261500
Name:WATAL, PANKAJ (MD)
Entity Type:Individual
Prefix:
First Name:PANKAJ
Middle Name:
Last Name:WATAL
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:10140 CENTURION PARKWAY N
Mailing Address - Street 2:FL PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-0532
Mailing Address - Country:US
Mailing Address - Phone:904-697-4100
Mailing Address - Fax:904-697-5102
Practice Address - Street 1:6535 NEMOURS PKWY
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-7884
Practice Address - Country:US
Practice Address - Phone:407-567-4000
Practice Address - Fax:407-567-5924
Is Sole Proprietor?:No
Enumeration Date:2015-07-22
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IAR-101752085N0700X
DEC1-00130542085P0229X
FLME1395152085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102951100Medicaid