Provider Demographics
NPI:1790886430
Name:MIGUELENA, MATTHEW JON (RPT)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:JON
Last Name:MIGUELENA
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 W LOS ANGELES AVE
Mailing Address - Street 2:#145
Mailing Address - City:MOORPARK
Mailing Address - State:CA
Mailing Address - Zip Code:93021
Mailing Address - Country:US
Mailing Address - Phone:805-300-2426
Mailing Address - Fax:
Practice Address - Street 1:13660 BLACKSMITH CT
Practice Address - Street 2:
Practice Address - City:MOORPARK
Practice Address - State:CA
Practice Address - Zip Code:93021
Practice Address - Country:US
Practice Address - Phone:805-300-2426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT19275225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT19275Medicare ID - Type Unspecified