Provider Demographics
NPI:1629198544
Name:JACK M. MATHENY II, MD
Entity type:Organization
Organization Name:JACK M. MATHENY II, MD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:SATISH
Authorized Official - Middle Name:
Authorized Official - Last Name:RAVI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-328-6746
Mailing Address - Street 1:700 ZEAGLER DR STE 10
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-3826
Mailing Address - Country:US
Mailing Address - Phone:386-328-6746
Mailing Address - Fax:386-328-7554
Practice Address - Street 1:700 ZEAGLER DR STE 10
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-3826
Practice Address - Country:US
Practice Address - Phone:386-328-6746
Practice Address - Fax:386-328-7554
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JACK M MATHENY II MD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-02
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL372143401Medicaid
FL372143401Medicaid
FL39790Medicare PIN