Provider Demographics
NPI:1508853318
Name:MADIWALE, TAJ M (MD)
Entity Type:Individual
Prefix:DR
First Name:TAJ
Middle Name:M
Last Name:MADIWALE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 SW 62ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-3009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3100 SW 62ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-3009
Practice Address - Country:US
Practice Address - Phone:305-666-6511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1124342080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009962025Medicaid
FL006684600Medicaid
AL051522393OtherBCBS PROVIDER NUMBER
AL009962025Medicaid