Healthcare Provider Details

I. General information

NPI: 1083811467
Provider Name (Legal Business Name): MATTHEW KEVIN WALSWORTH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

227 MADISON ST
NEW YORK NY
10002-7537
US

IV. Provider business mailing address

615 KINGMAN AVE
SANTA MONICA CA
90402-1333
US

V. Phone/Fax

Practice location:
  • Phone: 212-238-7000
  • Fax:
Mailing address:
  • Phone: 310-301-6800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA119553
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberA119553
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number347323
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number347323
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: