Provider Demographics
NPI:1700886660
Name:MICK, MATTHEW J (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:J
Last Name:MICK
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 1:6175 RIVERLAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:BARTOW
Mailing Address - State:FL
Mailing Address - Zip Code:33830-7754
Mailing Address - Country:US
Mailing Address - Phone:414-559-2141
Mailing Address - Fax:863-646-7292
Practice Address - Street 1:6175 RIVERLAKE BLVD
Practice Address - Street 2:
Practice Address - City:BARTOW
Practice Address - State:FL
Practice Address - Zip Code:33830-7754
Practice Address - Country:US
Practice Address - Phone:414-559-2141
Practice Address - Fax:863-646-7292
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI35056207RC0000X
AL00027578207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009939093Medicaid
AL51536934Medicare ID - Type Unspecified
AL009939093Medicaid