Provider Demographics
NPI:1740254713
Name:ROUEL, WADI (MD)
Entity type:Individual
Prefix:DR
First Name:WADI
Middle Name:
Last Name:ROUEL
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 1:4060 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92105-1608
Mailing Address - Country:US
Mailing Address - Phone:619-584-1612
Mailing Address - Fax:619-281-6738
Practice Address - Street 1:4060 FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-1608
Practice Address - Country:US
Practice Address - Phone:619-584-1612
Practice Address - Fax:619-281-6738
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC55979207R00000X
FLME92300207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL279346600Medicaid
FL03370YMedicare PIN
FL279346600Medicaid