1386741114 NPI number — DR. SEPALIKA WASANTHALAL M.D.

Table of content: DR. SEPALIKA WASANTHALAL M.D. (NPI 1386741114)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386741114 NPI number — DR. SEPALIKA WASANTHALAL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WASANTHALAL
Provider First Name:
SEPALIKA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386741114
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/17/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
460 PINE HOLLOW LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST PALM BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33413-2255
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-684-6129
Provider Business Mailing Address Fax Number:
561-357-9460

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5053 SOUTH CONGRESS AVE
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
ATLANTIS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33462
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-357-9060
Provider Business Practice Location Address Fax Number:
561-357-9460
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X , with the licence number:  ME0067628 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2451100200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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