Provider Demographics
NPI:1639373608
Name:WONG, MATTHEW (PT)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3435 OCEAN PARK BLVD
Mailing Address - Street 2:#107
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-3301
Mailing Address - Country:US
Mailing Address - Phone:310-430-3881
Mailing Address - Fax:
Practice Address - Street 1:3435 OCEAN PARK BLVD
Practice Address - Street 2:#107
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-3301
Practice Address - Country:US
Practice Address - Phone:310-430-3881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT16107225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist