Provider Demographics
NPI:1578399747
Name:JACK M MATHENY II, MD, LLC
Entity type:Organization
Organization Name:JACK M MATHENY II, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SATISH
Authorized Official - Middle Name:V
Authorized Official - Last Name:RAVI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-328-6746
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:
Mailing Address - Fax:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-12
Last Update Date:2024-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health