Provider Demographics
NPI:1922261312
Name:MATSUMOTO, MIWA (PT)
Entity Type:Individual
Prefix:
First Name:MIWA
Middle Name:
Last Name:MATSUMOTO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:860 JOHNSON FERRY RD NE
Practice Address - Street 2:SUITE 100
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1435
Practice Address - Country:US
Practice Address - Phone:404-252-5545
Practice Address - Fax:404-252-5511
Is Sole Proprietor?:No
Enumeration Date:2008-07-07
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT9348225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00626895OtherRAILROAD MEDICARE
GA511I250034Medicare PIN
GAP00626895OtherRAILROAD MEDICARE