Provider Demographics
NPI:1346432309
Name:MATEJA, MARK R (DPT/PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:MATEJA
Suffix:
Gender:M
Credentials:DPT/PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 JARRETT WHITE RD
Mailing Address - Street 2:
Mailing Address - City:TRIPLER AMC
Mailing Address - State:HI
Mailing Address - Zip Code:96859-5001
Mailing Address - Country:US
Mailing Address - Phone:808-433-6661
Mailing Address - Fax:808-433-1551
Practice Address - Street 1:1 JARRETT WHITE RD
Practice Address - Street 2:
Practice Address - City:TRIPLER AMC
Practice Address - State:HI
Practice Address - Zip Code:96859-5001
Practice Address - Country:US
Practice Address - Phone:808-433-6661
Practice Address - Fax:808-433-1551
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2154225100000X
MEPT4639225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1346432309Medicaid
NVV104484Medicare PIN