Provider Demographics
NPI:1568086932
Name:MATAWALLE, FIRDAUSI (MD)
Entity type:Individual
Prefix:MRS
First Name:FIRDAUSI
Middle Name:
Last Name:MATAWALLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1824 GOOD HOPE RD
Mailing Address - Street 2:
Mailing Address - City:ENOLA
Mailing Address - State:PA
Mailing Address - Zip Code:17025-1233
Mailing Address - Country:US
Mailing Address - Phone:717-732-8877
Mailing Address - Fax:717-732-9241
Practice Address - Street 1:1824 GOOD HOPE RD
Practice Address - Street 2:
Practice Address - City:ENOLA
Practice Address - State:PA
Practice Address - Zip Code:17025-1233
Practice Address - Country:US
Practice Address - Phone:717-732-8877
Practice Address - Fax:717-732-9241
Is Sole Proprietor?:No
Enumeration Date:2020-06-02
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD481284207R00000X, 207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program