Provider Demographics
NPI:1811258130
Name:DEWALD, TAD PALMER
Entity type:Individual
Prefix:
First Name:TAD
Middle Name:PALMER
Last Name:DEWALD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3683 S MIAMI AVE STE 460
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33133-4238
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3683 S MIAMI AVE STE 460
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33133-4238
Practice Address - Country:US
Practice Address - Phone:305-459-3377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-04
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.354182081S0010X
AZ544662081S0010X
FLME1627382081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ279012Medicaid