MEDICARE: DR. MATT SPENCER LALLAS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0402X	Neurology with Special Qualifications in Child Neurology Physician	A116424	CA
2	2084N0600X	Clinical Neurophysiology Physician	A116424	CA
3	2084N0600X	Clinical Neurophysiology Physician	ME118674	FL
4	2084N0402X	Neurology with Special Qualifications in Child Neurology Physician	ME118674	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700170180
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MATT SPENCER LALLAS M.D.

Provider Business Mailing Address
First Line	:	3200 SW 60TH CT STE 302
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33155-4071
Country	:	US
Telephone Number	:	305-662-8330
Fax Number	:

Provider Business Practice Location Address
First Line	:	3200 SW 60TH CT STE 302
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33155-4071
Country	:	US
Telephone Number	:	954-371-0107
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/03/2011
Last Update Date	:	07/14/2022

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