Healthcare Provider Details

I. General information

NPI: 1144843111
Provider Name (Legal Business Name): VAHE MATNISHIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2020
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3515 SE WILLOUGHBY BLVD
STUART FL
34994-5059
US

IV. Provider business mailing address

3515 SE WILLOUGHBY BLVD
STUART FL
34994-5059
US

V. Phone/Fax

Practice location:
  • Phone: 772-283-3800
  • Fax:
Mailing address:
  • Phone: 772-283-3800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO4608
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberPO4608
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberPO4608
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: