Healthcare Provider Details

I. General information

NPI: 1629066980
Provider Name (Legal Business Name): JEAN-WILNER MATHIEU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 02/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1234 NE 4TH AVE SUITE A
FORT LAUDERDALE FL
33304-1925
US

IV. Provider business mailing address

1234 NE 4TH AVE SUITE A
FORT LAUDERDALE FL
33304-1925
US

V. Phone/Fax

Practice location:
  • Phone: 954-779-1667
  • Fax: 954-760-7253
Mailing address:
  • Phone: 954-779-1667
  • Fax: 954-760-7253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME 0042195
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME 0042195
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: