Provider Demographics
NPI:1437042785
Name:JACK M MATHENY II, MD, LLC
Entity type:Organization
Organization Name:JACK M MATHENY II, MD, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SATISH
Authorized Official - Middle Name:
Authorized Official - Last Name:RAVI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-227-6768
Mailing Address - Street 1:PO BOX 330196
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32233-0196
Mailing Address - Country:US
Mailing Address - Phone:386-227-6768
Mailing Address - Fax:
Practice Address - Street 1:800 ZEAGLER DR STE 400
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-3827
Practice Address - Country:US
Practice Address - Phone:386-227-6768
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-03
Last Update Date:2025-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health