1720363138 NPI number — MR. MATTHEW KEITH YELKEN PA

Table of content: MR. MATTHEW KEITH YELKEN PA (NPI 1720363138)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720363138 NPI number — MR. MATTHEW KEITH YELKEN PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
YELKEN
Provider First Name:
MATTHEW
Provider Middle Name:
KEITH
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720363138
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/17/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2901 SW 41ST ST
Provider Second Line Business Mailing Address:
APT. 2304
Provider Business Mailing Address City Name:
OCALA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34474-7449
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-984-0003
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1901 SE 18TH AVE
Provider Second Line Business Practice Location Address:
#400
Provider Business Practice Location Address City Name:
OCALA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34471-8215
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-732-8905
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/17/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA9106226 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 012139700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".