Provider Demographics
NPI:1659361749
Name:SMITH, MATTHEW L (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:L
Last Name:SMITH
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 1:17011 STATE ROAD 50 STE 103
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-8203
Mailing Address - Country:US
Mailing Address - Phone:310-721-3793
Mailing Address - Fax:
Practice Address - Street 1:17011 STATE ROAD 50 STE 103
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-8203
Practice Address - Country:US
Practice Address - Phone:310-721-3793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME98015207KA0200X, 207Q00000X, 2080A0000X, 208D00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL277908100Medicaid