MEDICARE: MR. MATTHEW GUTSTADT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	000787000	FL

General Provider Information

NPI Number	:	1013660240
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MATTHEW GUTSTADT

Provider Business Mailing Address
First Line	:	750 NE 24TH WAY
Second Line	:
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33304-3569
Country	:	US
Telephone Number	:	954-557-0319
Fax Number	:

Provider Business Practice Location Address
First Line	:	750 NE 24TH WAY
Second Line	:
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33304-3569
Country	:	US
Telephone Number	:	954-557-0319
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/28/2022
Last Update Date	:	01/29/2022

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Directions to “ MR. MATTHEW GUTSTADT ” Practice Location

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