Provider Demographics
NPI:1922044742
Name:MADIWALE, KATHARYN (DO)
Entity Type:Individual
Prefix:DR
First Name:KATHARYN
Middle Name:
Last Name:MADIWALE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:6101 BLUE LAGOON DR STE 400
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-2051
Mailing Address - Country:US
Mailing Address - Phone:954-434-1705
Mailing Address - Fax:800-642-2398
Practice Address - Street 1:350 NW 84TH AVE STE 200A
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-1817
Practice Address - Country:US
Practice Address - Phone:954-424-4321
Practice Address - Fax:954-424-0765
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2019-01-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLOS 11738207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006610600Medicaid
FL14MQ5OtherFLORIDA BLUE
FL14MQ5OtherFLORIDA BLUE