Basic Information
| Provider Information | |||||||||
| NPI: | 1841371697 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STANDRIDGE | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3900 ESPLANADE WAY | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323110802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504313867 | ||||||||
| FaxNumber: | 8504313879 | ||||||||
| Practice Location | |||||||||
| Address1: | 15 COUNCIL MOORE RD | ||||||||
| Address2: | |||||||||
| City: | CRAWFORDVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323273117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8509267105 | ||||||||
| FaxNumber: | 8509262034 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 04/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 44268 | CO | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 200700809 | NC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | ME109430 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 003679200 | 05 | FL | MEDICAID | 14EN3 | 01 | FL | BCBS | OTHER |