Healthcare Provider Details

I. General information

NPI: 1205754066
Provider Name (Legal Business Name): MATTHEW RYAN MITCHELL RD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2026
Last Update Date: 07/08/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7042 W FLAGLER ST
MIAMI FL
33144-2758
US

IV. Provider business mailing address

7042 W FLAGLER ST
MIAMI FL
33144-2758
US

V. Phone/Fax

Practice location:
  • Phone: 786-275-0400
  • Fax:
Mailing address:
  • Phone: 786-275-0400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86446774
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: