Healthcare Provider Details

I. General information

NPI: 1780145219
Provider Name (Legal Business Name): MATTHEW ALEXANDER HECKROTH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2019
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 W TOWN PL STE 109
ST AUGUSTINE FL
32092-3648
US

IV. Provider business mailing address

4800 BELFORT RD
JACKSONVILLE FL
32256-6004
US

V. Phone/Fax

Practice location:
  • Phone: 904-398-7205
  • Fax:
Mailing address:
  • Phone: 904-398-7205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME161079
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberME161079
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: