MEDICARE: JACK M MATHENY II

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	207Q00000X	Family Medicine Physician	ME0048571	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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629040043
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK M MATHENY II

Provider Business Mailing Address
First Line	:	700 ZEAGLER DR STE 10
Second Line	:
City	:	PALATKA
State	:	FL
Zip	:	32177-3826
Country	:	US
Telephone Number	:	386-328-6746
Fax Number	:	386-328-7554

Provider Business Practice Location Address
First Line	:	700 ZEAGLER DR STE 10
Second Line	:
City	:	PALATKA
State	:	FL
Zip	:	32177-3826
Country	:	US
Telephone Number	:	386-328-6746
Fax Number	:	386-328-7554

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

Provider Enumeration Date	:	02/02/2006
Last Update Date	:	04/02/2019

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Directions to “ JACK M MATHENY II ” Practice Location

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