Provider Demographics
NPI:1730679234
Name:BEALE, MATTHEW THOMAS (CPO)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:THOMAS
Last Name:BEALE
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1084 N EL CAMINO REAL STE B
Mailing Address - Street 2:#122
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024
Mailing Address - Country:US
Mailing Address - Phone:925-407-6904
Mailing Address - Fax:
Practice Address - Street 1:137 PORTLAND ST
Practice Address - Street 2:4TH FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114
Practice Address - Country:US
Practice Address - Phone:617-996-9058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-10
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPS61292556OtherWASHINGTON STATE DEPARTMENT OF HEALTH PROSTHETIST LICENSE
CPO03996OtherAMERICAN BOARD FOR CERTIFICATION (ORTHOTICS, PROSTHETICS, PEDORTHICS
WAOI61292553OtherWASHINGTON STATE DEPARTMENT OF HEALTH ORTHOTIST LICENSE