Provider Demographics
NPI:1073503231
Name:DEXTER, MATTHEW (PT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:DEXTER
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 1:1333 TONKAWOOD DR
Mailing Address - Street 2:
Mailing Address - City:TALLMADGE
Mailing Address - State:OH
Mailing Address - Zip Code:44278-2682
Mailing Address - Country:US
Mailing Address - Phone:330-630-9327
Mailing Address - Fax:330-633-3505
Practice Address - Street 1:116 EAST AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:TALLMADGE
Practice Address - State:OH
Practice Address - Zip Code:44278-2328
Practice Address - Country:US
Practice Address - Phone:330-633-3656
Practice Address - Fax:330-633-3505
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH7554225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000138915OtherANTHEM
OH2244619Medicaid
OHS87991Medicare UPIN
OH0882361Medicare ID - Type Unspecified