Healthcare Provider Details

I. General information

NPI: 1811258130
Provider Name (Legal Business Name): TAD PALMER DEWALD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2012
Last Update Date: 09/05/2023
Certification Date: 09/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3683 S MIAMI AVE STE 460
MIAMI FL
33133-4238
US

IV. Provider business mailing address

3683 S MIAMI AVE STE 460
MIAMI FL
33133-4238
US

V. Phone/Fax

Practice location:
  • Phone: 305-459-3377
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberMD.35418
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number54466
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberME162738
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: