Provider Demographics
NPI:1205928454
Name:MATSON, RAYMOND (MD)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:MATSON
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 1:3033 W 30TH CT
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:707 JENKS AVE
Practice Address - Street 2:SUITE A
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-2586
Practice Address - Country:US
Practice Address - Phone:850-747-5272
Practice Address - Fax:850-747-5274
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QF0400X
FLME65991207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL64263OtherBLUE CROSS BLUE SHIELD
FLD76089Medicare UPIN