Provider Demographics
NPI:1851495030
Name:SMITH, MATTHEW EDWIN (DPT)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:EDWIN
Last Name:SMITH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 E WADSWORTH PARK DR STE 230
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-8096
Mailing Address - Country:US
Mailing Address - Phone:208-899-3724
Mailing Address - Fax:
Practice Address - Street 1:65 E WADSWORTH PARK DR STE 230
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-8096
Practice Address - Country:US
Practice Address - Phone:208-899-3724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA25955225100000X
OR61680225100000X
ND1694225100000X
MTPTP-PT-LIC-13927225100000X
MEPT6071225100000X
KS11-06915225100000X
MN10529225100000X
ALPTH10586225100000X
NV4722225100000X
NMPT6056225100000X
MI5501301784225100000X
CA301958225100000X
IDPT-1901225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1655555Medicare PIN