Provider Demographics
NPI:1265403406
Name:MATTEUCCI, MICHAEL JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
Last Name:MATTEUCCI
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:NAS JACKSONVILLE, BUILDING 554
Mailing Address - Street 2:BUREAU OF MEDICINE AND SURGERY DETACHMENT JACKSONVILLE
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32212-0140
Mailing Address - Country:US
Mailing Address - Phone:877-722-4373
Mailing Address - Fax:
Practice Address - Street 1:NAS JACKSONVILLE, BUILDING 554
Practice Address - Street 2:BUREAU OF MEDICINE AND SURGERY DETACHMENT
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32212-0140
Practice Address - Country:US
Practice Address - Phone:877-722-4373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA64549207P00000X, 207PT0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PT0002XAllopathic & Osteopathic PhysiciansEmergency MedicineMedical Toxicology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A645490Medicaid
CAWA64549BMedicare PIN
I05718Medicare UPIN