Healthcare Provider Details

I. General information

NPI: 1578158333
Provider Name (Legal Business Name): OTAKHON MATCHANOV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2021
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12600 CREEKSIDE LN STE 2
FORT MYERS FL
33919-3353
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-343-9235
  • Fax:
Mailing address:
  • Phone: 239-343-9235
  • Fax: 239-343-4008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME182444
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number338571-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: