Healthcare Provider Details

I. General information

NPI: 1821075219
Provider Name (Legal Business Name): MICHAEL JON MATTICE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2005
Last Update Date: 06/17/2020
Certification Date: 06/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3725 10TH COURT
VERO BEACH FL
32960
US

IV. Provider business mailing address

3725 10TH COURT
VERO BEACH FL
32960
US

V. Phone/Fax

Practice location:
  • Phone: 772-213-3621
  • Fax: 772-213-3631
Mailing address:
  • Phone: 772-213-3621
  • Fax: 772-213-3631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083T0002X
TaxonomyMedical Toxicology (Preventive Medicine) Physician
License NumberME0049088
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: