MEDICARE: DR. MATTHEW JULIAN WIDEROFF M.D.

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	208600000X	Surgery Physician	ME167382	FL
2	208600000X	Surgery Physician	9934	SD

General Provider Information

NPI Number	:	1134448129
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MATTHEW JULIAN WIDEROFF M.D.

Provider Business Mailing Address
First Line	:	PO BOX 935921
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	31193-5921
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	61 MEMORIAL MEDICAL PKWY STE 3805
Second Line	:
City	:	PALM COAST
State	:	FL
Zip	:	32164-5982
Country	:	US
Telephone Number	:	386-586-1605
Fax Number	:	386-586-1607

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

Provider Enumeration Date	:	05/31/2010
Last Update Date	:	08/07/2024

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