Provider Demographics
NPI:1225056062
Name:MATUKAITIS, TODD (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:MATUKAITIS
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11240 WAPLES MILL ROAD
Mailing Address - Street 2:SUITE 403
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030
Mailing Address - Country:US
Mailing Address - Phone:703-385-4707
Mailing Address - Fax:703-691-4933
Practice Address - Street 1:2875 DUKE ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314
Practice Address - Country:US
Practice Address - Phone:703-751-7660
Practice Address - Fax:703-751-5880
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305204034225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA018474C95Medicare ID - Type Unspecified