Basic Information
| Provider Information | |||||||||
| NPI: | 1962486027 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JEPSEN | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | CARL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JEPSEN | ||||||||
| OtherFirstName: | MATTHEW | ||||||||
| OtherMiddleName: | C | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 133 BENMORE DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | WINTER PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327924111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076444883 | ||||||||
| FaxNumber: | 4076443697 | ||||||||
| Practice Location | |||||||||
| Address1: | 133 BENMORE DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | WINTER PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327924111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076444883 | ||||||||
| FaxNumber: | 4076443697 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2005 | ||||||||
| LastUpdateDate: | 05/13/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 378872-1205 | UT | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | 46765 | MN | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | ME149465 | FL | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
No ID Information.