Provider Demographics
NPI:1578505368
Name:MIDWALL, JAY A (MD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:A
Last Name:MIDWALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5503 S CONGRESS AVE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:ATLANTIS
Mailing Address - State:FL
Mailing Address - Zip Code:33462-6625
Mailing Address - Country:US
Mailing Address - Phone:561-433-0591
Mailing Address - Fax:561-433-0891
Practice Address - Street 1:5503 S CONGRESS AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:ATLANTIS
Practice Address - State:FL
Practice Address - Zip Code:33462-6625
Practice Address - Country:US
Practice Address - Phone:561-433-0591
Practice Address - Fax:561-433-0891
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME34420207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL098241800Medicaid
FL95245OtherBCBS
FLP00609970OtherRAIL ROAD MEDICARE
FL95245OtherBCBS
FLD63381Medicare UPIN
FLP00609970OtherRAIL ROAD MEDICARE