Provider Demographics
NPI:1326331869
Name:CONN, MATTHEW RICHARD (DPT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RICHARD
Last Name:CONN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 711185
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84171-1185
Mailing Address - Country:US
Mailing Address - Phone:801-942-3311
Mailing Address - Fax:801-942-5955
Practice Address - Street 1:1153 E 3900 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1201
Practice Address - Country:US
Practice Address - Phone:801-262-6331
Practice Address - Fax:801-262-3372
Is Sole Proprietor?:No
Enumeration Date:2011-05-17
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7977639-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT466502Medicare Oscar/Certification