Provider Demographics
NPI:1083702963
Name:MCKILLOP, MATTHEW STEPHEN (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:STEPHEN
Last Name:MCKILLOP
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 43667
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32203-3667
Mailing Address - Country:US
Mailing Address - Phone:904-720-0599
Mailing Address - Fax:904-376-4036
Practice Address - Street 1:559 W TWINCOURT TRL UNIT 601
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32095-8805
Practice Address - Country:US
Practice Address - Phone:904-493-8383
Practice Address - Fax:904-376-3209
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME96218207R00000X, 207RC0000X, 207RC0001X
SC61263207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003547000Medicaid
FLFA214ZMedicare PIN