Provider Demographics
NPI:1821075219
Name:MATTICE, MICHAEL JON (MD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JON
Last Name:MATTICE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3725 10TH COURT
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960
Mailing Address - Country:US
Mailing Address - Phone:772-213-3621
Mailing Address - Fax:772-213-3631
Practice Address - Street 1:3725 10TH COURT
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960
Practice Address - Country:US
Practice Address - Phone:772-213-3621
Practice Address - Fax:772-213-3631
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-27
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00490882083T0002X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes2083T0002XAllopathic & Osteopathic PhysiciansPreventive MedicineMedical Toxicology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME0049088OtherMEDICAL LICENSE
FLME0049088OtherMEDICAL LICENSE
FL02052BMedicare PIN