Provider Demographics
NPI:1578823654
Name:MATT, PATRICK MARSHALL (DO)
Entity type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:MARSHALL
Last Name:MATT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:13607 PINE VILLA LN
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-1617
Mailing Address - Country:US
Mailing Address - Phone:239-424-3123
Mailing Address - Fax:239-424-4041
Practice Address - Street 1:13607 PINE VILLA LN
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-1617
Practice Address - Country:US
Practice Address - Phone:239-424-3123
Practice Address - Fax:239-424-4041
Is Sole Proprietor?:No
Enumeration Date:2012-05-22
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS13260207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015322600Medicaid