Provider Demographics
NPI:1114963618
Name:MAULTSBY, DWAYNE ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:DWAYNE
Middle Name:ALAN
Last Name:MAULTSBY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:DWAYNE
Other - Middle Name:A
Other - Last Name:MAULTSBY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 640996
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33164
Mailing Address - Country:US
Mailing Address - Phone:954-720-3188
Mailing Address - Fax:954-586-2589
Practice Address - Street 1:7154 N UNIVERSITY DR
Practice Address - Street 2:#316
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-2916
Practice Address - Country:US
Practice Address - Phone:954-720-3188
Practice Address - Fax:954-586-2589
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME106616207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200083200AMedicaid
OKOKA103457Medicare PIN
OK200083200AMedicaid