Healthcare Provider Details

I. General information

NPI: 1700269206
Provider Name (Legal Business Name): MATTHEW THOMAS CAPALBO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2015
Last Update Date: 09/12/2023
Certification Date: 09/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

859 WINTER ST
LUCEDALE MS
39452-6603
US

IV. Provider business mailing address

PO BOX 1007
LUCEDALE MS
39452-1007
US

V. Phone/Fax

Practice location:
  • Phone: 601-947-3161
  • Fax: 601-947-1331
Mailing address:
  • Phone: 601-947-1330
  • Fax: 601-947-1331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOT016675
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: