Provider Demographics
NPI:1083696884
Name:THOMPSON, MATTHEW KARL (RPT)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:KARL
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4957 ROSEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-7168
Mailing Address - Country:US
Mailing Address - Phone:321-951-2416
Mailing Address - Fax:321-951-2077
Practice Address - Street 1:308 S HARBOR CITY BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-1500
Practice Address - Country:US
Practice Address - Phone:321-951-2416
Practice Address - Fax:321-951-2077
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT10471225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL888624500Medicaid
FLY6308OtherBLUE CROSS/BLUE SHIELD PR
FLY6308OtherBLUE CROSS/BLUE SHIELD PR