Provider Demographics
NPI:1104871979
Name:KINZELMAN, MATTHEW G (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:G
Last Name:KINZELMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2699
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32513-2699
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3754 HIGHWAY 90
Practice Address - Street 2:200
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-1020
Practice Address - Country:US
Practice Address - Phone:850-416-5200
Practice Address - Fax:850-416-5201
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME40346207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL067014600Medicare ID - Type Unspecified
FLD53399Medicare UPIN
FL20056Medicare ID - Type Unspecified