Provider Demographics
NPI:1760947295
Name:PIKOWSKI, MATTHEW DITTRICH
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DITTRICH
Last Name:PIKOWSKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3262 W 110TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60655-2737
Mailing Address - Country:US
Mailing Address - Phone:773-490-7666
Mailing Address - Fax:
Practice Address - Street 1:3262 W 110TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60655-2737
Practice Address - Country:US
Practice Address - Phone:773-490-7666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer