Basic Information
| Provider Information | |||||||||
| NPI: | 1700261500 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATAL | ||||||||
| FirstName: | PANKAJ | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10140 CENTURION PARKWAY N | ||||||||
| Address2: | FL PROVIDER ENROLLMENT | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322560532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046974100 | ||||||||
| FaxNumber: | 9046975102 | ||||||||
| Practice Location | |||||||||
| Address1: | 6535 NEMOURS PKWY | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328277884 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4075674000 | ||||||||
| FaxNumber: | 4075675924 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2015 | ||||||||
| LastUpdateDate: | 09/22/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0700X | R-10175 | IA | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085P0229X | C1-0013054 | DE | N | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085P0229X | ME139515 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology |
ID Information
| ID | Type | State | Issuer | Description | 102951100 | 05 | FL | MEDICAID |