Provider Demographics
NPI:1346291259
Name:MERRELL, MATTHEW M (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:M
Last Name:MERRELL
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 1:12109 COUNTY ROAD 103
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:FL
Mailing Address - Zip Code:34484-2951
Mailing Address - Country:US
Mailing Address - Phone:352-205-8981
Mailing Address - Fax:
Practice Address - Street 1:545 HEALTH BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-1493
Practice Address - Country:US
Practice Address - Phone:386-239-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME80554208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
35978OtherBLUE SHIELD
FL264743500Medicaid
340018344OtherRR MEDICARE
35978OtherBLUE SHIELD
35978OtherBLUE SHIELD
1900206OtherUNITED HEALTHCARE