Healthcare Provider Details

I. General information

NPI: 1801543004
Provider Name (Legal Business Name): MATTHEW USMILLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2022
Last Update Date: 03/07/2022
Certification Date: 03/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12509 OAK FOREST DR
GULFPORT MS
39503-5730
US

IV. Provider business mailing address

12509 OAK FOREST DR
GULFPORT MS
39503-5730
US

V. Phone/Fax

Practice location:
  • Phone: 228-860-5636
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86070183
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: