Provider Demographics
NPI:1265627608
Name:WORTHALTER, PEYSAF (MD)
Entity type:Individual
Prefix:
First Name:PEYSAF
Middle Name:
Last Name:WORTHALTER
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 1:20824 W DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33180-1147
Mailing Address - Country:US
Mailing Address - Phone:305-654-0907
Mailing Address - Fax:305-999-0011
Practice Address - Street 1:20824 W DIXIE HWY
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33180-1147
Practice Address - Country:US
Practice Address - Phone:305-654-0907
Practice Address - Fax:305-999-0011
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-10
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME411252084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL039728800Medicaid
FL96159OtherBCBS
FL96159OtherBCBS
FLB88986Medicare UPIN