Provider Demographics
NPI:1104047893
Name:DEBOER, MATTHEW RYAN (DO)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:RYAN
Last Name:DEBOER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 746638
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6638
Mailing Address - Country:US
Mailing Address - Phone:904-202-2092
Mailing Address - Fax:904-376-4075
Practice Address - Street 1:1310 COUNTY ROAD 210 W
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259
Practice Address - Country:US
Practice Address - Phone:904-824-4407
Practice Address - Fax:904-390-7459
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2024-11-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLOS10998207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00855555OtherRR MEDICARE
FLDF177ZMedicare PIN
FLDF177ZMedicare PIN