Provider Demographics
NPI:1609908870
Name:MATZOLL, JOHN DAVID (ATC)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:DAVID
Last Name:MATZOLL
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1350 GARDENA AVE NE
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-5830
Mailing Address - Country:US
Mailing Address - Phone:763-571-9116
Mailing Address - Fax:763-571-9118
Practice Address - Street 1:1350 GARDENA AVE NE
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-5830
Practice Address - Country:US
Practice Address - Phone:763-571-9116
Practice Address - Fax:763-571-9118
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12042255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer