Basic Information
| Provider Information | |||||||||
| NPI: | 1639303456 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IMBT | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | MATHEW | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 820 PRUDENTIAL DR | ||||||||
| Address2: | SUITE 713 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043965682 | ||||||||
| FaxNumber: | 9043460864 | ||||||||
| Practice Location | |||||||||
| Address1: | 820 PRUDENTIAL DR | ||||||||
| Address2: | SUITE 713 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043965682 | ||||||||
| FaxNumber: | 9043460864 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2009 | ||||||||
| LastUpdateDate: | 08/27/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | ME113769 | FL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.