Provider Demographics
NPI:1629040043
Name:MATHENY, JACK M II
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:M
Last Name:MATHENY
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 ZEAGLER DR STE 10
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-3826
Mailing Address - Country:US
Mailing Address - Phone:386-328-6746
Mailing Address - Fax:386-328-7554
Practice Address - Street 1:700 ZEAGLER DR STE 10
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-3826
Practice Address - Country:US
Practice Address - Phone:386-328-6746
Practice Address - Fax:386-328-7554
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-02
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0048571207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL046979300Medicaid
FL372143400OtherMEDICAID GROUP NUMBER FOR NON RURAL HEALTH SERVICES
FL372143401OtherMEDICAID GROUP NUMBER FOR RURAL HEALTH CLINIC
39790Medicare PIN
FL046979300Medicaid
FL372143401OtherMEDICAID GROUP NUMBER FOR RURAL HEALTH CLINIC
04357Medicare PIN