Provider Demographics
NPI:1386741114
Name:WASANTHALAL, SEPALIKA (MD)
Entity type:Individual
Prefix:DR
First Name:SEPALIKA
Middle Name:
Last Name:WASANTHALAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 PINE HOLLOW LN
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33413-2255
Mailing Address - Country:US
Mailing Address - Phone:561-684-6129
Mailing Address - Fax:561-357-9460
Practice Address - Street 1:5053 SOUTH CONGRESS AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:ATLANTIS
Practice Address - State:FL
Practice Address - Zip Code:33462
Practice Address - Country:US
Practice Address - Phone:561-357-9060
Practice Address - Fax:561-357-9460
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0067628207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2451100200Medicaid
28936Medicare ID - Type Unspecified
FL2451100200Medicaid