1629196183 NPI number — DR. MATTHEW WALKER ALLEN IV DDS

Table of content: DR. MATTHEW WALKER ALLEN IV DDS (NPI 1629196183)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629196183 NPI number — DR. MATTHEW WALKER ALLEN IV DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ALLEN IV
Provider First Name:
MATTHEW
Provider Middle Name:
WALKER
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
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:
1629196183
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1871 COLONIAL BLVD
Provider Second Line Business Mailing Address:
STE 101
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33907-1315
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-936-7207
Provider Business Mailing Address Fax Number:
239-939-4019

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1871 COLONIAL BLVD
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
FORT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33907-1315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-936-7207
Provider Business Practice Location Address Fax Number:
239-939-4019
Provider Enumeration Date:
03/26/2007

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: 1223G0001X , with the licence number:  00003883 , 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)





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