Provider Demographics
NPI:1033131560
Name:SMITH, MATTHEW ALAN (PT)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:ALAN
Last Name:SMITH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 PALMER CIR
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-9547
Mailing Address - Country:US
Mailing Address - Phone:916-351-9035
Mailing Address - Fax:916-983-5615
Practice Address - Street 1:1635 CREEKSIDE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-3830
Practice Address - Country:US
Practice Address - Phone:916-983-5611
Practice Address - Fax:916-983-5615
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16050225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP56524Medicare UPIN
CAOPT160500Medicare ID - Type Unspecified