Provider Demographics
NPI:1821595513
Name:FOOTE, MATTHEW ZACHARIAH
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ZACHARIAH
Last Name:FOOTE
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 1:2814 S GREENWOOD DR APT 15
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-3214
Mailing Address - Country:US
Mailing Address - Phone:607-351-9389
Mailing Address - Fax:
Practice Address - Street 1:1081 JOHN ROBERT BELL DRIVE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-3760
Practice Address - Country:US
Practice Address - Phone:225-266-9343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN19592255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer