Provider Demographics
NPI:1417180886
Name:BRADDOCK, MATTHEW TODD (DO)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:TODD
Last Name:BRADDOCK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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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 1:810 LANE AVE S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32205-4785
Practice Address - Country:US
Practice Address - Phone:904-783-9680
Practice Address - Fax:904-390-7464
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-01
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLOS11091207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01085486OtherRAILROAD MEDICARE
FLP01627926OtherRR MEDICARE
FL005982200Medicaid
FLGI595ZMedicare PIN
FLGI595WMedicare PIN