=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124451471
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MID FLORIDA ENDOCRINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2013
-----------------------------------------------------
Last Update Date | 08/12/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 213 S DILLARD ST SUITE 240
-----------------------------------------------------
City | WINTER GARDEN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34787-3522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-614-1644
-----------------------------------------------------
Fax | 407-614-1635
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 213 S DILLARD ST SUITE 240
-----------------------------------------------------
City | WINTER GARDEN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34787-3522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-614-1644
-----------------------------------------------------
Fax | 407-614-1635
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | VICTOR MATTHEWS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 407-614-1644
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RE0101X
-----------------------------------------------------
Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------