Basic Information
| Provider Information | |||||||||
| NPI: | 1932527835 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALSH | ||||||||
| FirstName: | MATTHEW | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1611 NW 12TH AVE | ||||||||
| Address2: | WEST WING 279 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331361005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055857878 | ||||||||
| FaxNumber: | 3055855743 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 S ANDREWS AVE | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333162510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543555500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2014 | ||||||||
| LastUpdateDate: | 07/20/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | ME144313 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.