Provider Demographics
NPI:1710278171
Name:KUDRON, MATTHEW J (PT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:KUDRON
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 1:805 AEROVISTA PL
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-7919
Mailing Address - Country:US
Mailing Address - Phone:805-788-0805
Mailing Address - Fax:805-788-0845
Practice Address - Street 1:7483 E TANQUE VERDE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85715-3477
Practice Address - Country:US
Practice Address - Phone:520-207-7220
Practice Address - Fax:520-207-7109
Is Sole Proprietor?:No
Enumeration Date:2011-04-20
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9288PT225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist