Provider Demographics
NPI:1023768660
Name:MCGILLIVRAY, MATHEW ALBERT
Entity type:Individual
Prefix:
First Name:MATHEW
Middle Name:ALBERT
Last Name:MCGILLIVRAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 SW 96TH TER APT 201
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-2342
Mailing Address - Country:US
Mailing Address - Phone:617-901-5434
Mailing Address - Fax:
Practice Address - Street 1:703 N FLAMINGO RD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33028-1006
Practice Address - Country:US
Practice Address - Phone:954-844-1404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-26
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program