Healthcare Provider Details

I. General information

NPI: 1629198544
Provider Name (Legal Business Name): JACK M. MATHENY II, MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 09/02/2025
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 ZEAGLER DR STE 10
PALATKA FL
32177-3826
US

IV. Provider business mailing address

700 ZEAGLER DR STE 10
PALATKA FL
32177-3826
US

V. Phone/Fax

Practice location:
  • Phone: 386-328-6746
  • Fax: 386-328-7554
Mailing address:
  • Phone: 386-328-6746
  • Fax: 386-328-7554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SATISH RAVI
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 386-328-6746