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General NPI Number Information
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NPI Number | 1417180886
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Entity Type | Individual
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Provider Name | MATTHEW TODD BRADDOCK D.O.
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Gender | Male
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Dates
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Enumeration Date | 09/01/2009
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Last Update Date | 11/20/2024
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Provider Practice Location Address
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Address Line | 810 LANE AVE S
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City | JACKSONVILLE
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State | FL
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Zip | 32205-4785
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Country | US
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Telephone | 904-783-9680
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Fax | 904-390-7464
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Provider Business Mailing Address
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Address Line | PO BOX 746638
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City | ATLANTA
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State | GA
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Zip | 30374-6638
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Country | US
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Telephone | 904-202-2092
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Fax | 904-376-4075
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | OS11091
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License Number State | FL
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