Provider Demographics
NPI:1134448129
Name:WIDEROFF, MATTHEW JULIAN (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JULIAN
Last Name:WIDEROFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 935921
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-5921
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:61 MEMORIAL MEDICAL PKWY STE 3805
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-5982
Practice Address - Country:US
Practice Address - Phone:386-586-1605
Practice Address - Fax:386-586-1607
Is Sole Proprietor?:No
Enumeration Date:2010-05-31
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME167382208600000X
SD9934208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery