Provider Demographics
NPI:1700170180
Name:LALLAS, MATT SPENCER (MD)
Entity Type:Individual
Prefix:DR
First Name:MATT
Middle Name:SPENCER
Last Name:LALLAS
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 1:3200 SW 60TH CT STE 302
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-4071
Mailing Address - Country:US
Mailing Address - Phone:305-662-8330
Mailing Address - Fax:
Practice Address - Street 1:3200 SW 60TH CT STE 302
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-4071
Practice Address - Country:US
Practice Address - Phone:954-371-0107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-03
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1164242084N0402X, 2084N0600X
FLME1186742084N0600X, 2084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014784900Medicaid