Provider Demographics
NPI:1689040826
Name:VANDIVER, MATTHEW (DPT)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:
Last Name:VANDIVER
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 1:1055 FM 646 RD W
Mailing Address - Street 2:APT 1127
Mailing Address - City:DICKINSON
Mailing Address - State:TX
Mailing Address - Zip Code:77539-3581
Mailing Address - Country:US
Mailing Address - Phone:832-493-4300
Mailing Address - Fax:
Practice Address - Street 1:1887 E DESERT GARDEN DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85718-7840
Practice Address - Country:US
Practice Address - Phone:520-382-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-11
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11792225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist