Provider Demographics
NPI:1164105979
Name:TJANDRA, MATTHEW (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:
Last Name:TJANDRA
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 STEPPING STONE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92603-4244
Mailing Address - Country:US
Mailing Address - Phone:626-227-4829
Mailing Address - Fax:
Practice Address - Street 1:2135 WESTCLIFF DR STE 203
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-5543
Practice Address - Country:US
Practice Address - Phone:949-299-0297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-09
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA304539225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist