Basic Information
| Provider Information | |||||||||
| NPI: | 1003249004 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATTOX | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | MATTHEW | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10475 CENTURION PKWY N STE 201 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322565004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042233321 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 15255 MAX LEGGETT PKWY STE 5500 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322187273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042233321 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2013 | ||||||||
| LastUpdateDate: | 11/06/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171100000X | AC 15206 | CA | N | Other Service Providers | Acupuncturist | 171100000X | AP 3783 | FL | N | Other Service Providers | Acupuncturist | 363A00000X | PA9113748 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.