Provider Demographics
NPI:1568644342
Name:DEWAARD, MATTHEW JACOB
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JACOB
Last Name:DEWAARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1845 E COLGATE DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-2205
Mailing Address - Country:US
Mailing Address - Phone:480-897-2541
Mailing Address - Fax:480-897-2541
Practice Address - Street 1:1845 E COLGATE DR
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-2205
Practice Address - Country:US
Practice Address - Phone:480-897-2541
Practice Address - Fax:480-897-2541
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-03
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant