MEDICARE: MATTHEW JAMES KERR RD

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	133V00000X	Registered Dietitian	010974	NY
2	133V00000X	Registered Dietitian	DN007757	PA
3	133V00000X	Registered Dietitian	86102191	NJ
4	133V00000X	Registered Dietitian	LD.10046	OH
5	133V00000X	Registered Dietitian	LD2022016	NM
6	133V00000X	Registered Dietitian	LDN01235	RI
7	133V00000X	Registered Dietitian	ND9464	FL

General Provider Information

NPI Number	:	1659029585
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW JAMES KERR RD

Provider Business Mailing Address
First Line	:	981 WILMINGTON DR
Second Line	:
City	:	DELTONA
State	:	FL
Zip	:	32725-6524
Country	:	US
Telephone Number	:	386-228-5594
Fax Number	:

Provider Business Practice Location Address
First Line	:	5100 NW 33RD AVE STE 245
Second Line	:
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33309-6381
Country	:	US
Telephone Number	:	786-605-9055
Fax Number	:	913-676-7358

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

Provider Enumeration Date	:	03/10/2022
Last Update Date	:	02/10/2023

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