Basic Information
| Provider Information | |||||||||
| NPI: | 1922044742 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MADIWALE | ||||||||
| FirstName: | KATHARYN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6101 BLUE LAGOON DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331262051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544341705 | ||||||||
| FaxNumber: | 8006422398 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 NW 84TH AVE STE 200A | ||||||||
| Address2: | |||||||||
| City: | PLANTATION | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333241817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544244321 | ||||||||
| FaxNumber: | 9544240765 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 01/10/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS 11738 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 006610600 | 05 | FL | MEDICAID | 14MQ5 | 01 | FL | FLORIDA BLUE | OTHER |