Provider Demographics
NPI:1093700494
Name:ETHERIDGE, MATTHEW H (DPM)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:H
Last Name:ETHERIDGE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6160 N DAVIS HWY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-6994
Mailing Address - Country:US
Mailing Address - Phone:850-476-2805
Mailing Address - Fax:850-476-3010
Practice Address - Street 1:6160 N DAVIS HWY
Practice Address - Street 2:SUITE 1
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-6994
Practice Address - Country:US
Practice Address - Phone:850-476-2805
Practice Address - Fax:850-476-3010
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2862213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU80329Medicare UPIN
FLU80329Medicare UPIN