Provider Demographics
NPI:1467248161
Name:PADILLA, MATTHEW (RD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:PADILLA
Suffix:
Gender:
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2228 CANOPY TERRACE BLVD
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32724-9631
Mailing Address - Country:US
Mailing Address - Phone:407-330-8399
Mailing Address - Fax:
Practice Address - Street 1:2228 CANOPY TERRACE BLVD
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32724-9631
Practice Address - Country:US
Practice Address - Phone:407-330-8399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-17
Last Update Date:2025-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND12166133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered