Provider Demographics
NPI:1184671844
Name:JACK M. MATHENY II, M.D.
Entity Type:Organization
Organization Name:JACK M. MATHENY II, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:MEADOWS
Authorized Official - Last Name:MATHENY
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:386-328-6746
Mailing Address - Street 1:205 ZEAGLER DR
Mailing Address - Street 2:STE 101
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-3888
Mailing Address - Country:US
Mailing Address - Phone:328-328-6746
Mailing Address - Fax:
Practice Address - Street 1:205 ZEAGLER DR
Practice Address - Street 2:STE 101
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-3888
Practice Address - Country:US
Practice Address - Phone:328-328-6746
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JACK M MATHENY II MD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-28
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL372143401Medicaid
FL372143400Medicaid
FL372143401Medicaid
103846Medicare Oscar/Certification