Provider Demographics
NPI:1760610331
Name:BUCK, MATTHEW (PT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:BUCK
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 1:2853 S SOSSAMAN RD STE A106
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-9625
Mailing Address - Country:US
Mailing Address - Phone:480-373-9700
Mailing Address - Fax:
Practice Address - Street 1:16935 W BERNARDO DR STE 180
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92127-1621
Practice Address - Country:US
Practice Address - Phone:858-217-5837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-23
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA299172225100000X
TEMP LIC225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist