Provider Demographics
NPI:1942602230
Name:MARTIN, MATTHEW GORDON (PT,DPT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:GORDON
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1163 JOHNSON FERRY RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068-2764
Mailing Address - Country:US
Mailing Address - Phone:770-321-0155
Mailing Address - Fax:
Practice Address - Street 1:8400 HOLCOLM BRIDGE ROAD
Practice Address - Street 2:SUITE 480
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022
Practice Address - Country:US
Practice Address - Phone:770-640-5470
Practice Address - Fax:770-640-5471
Is Sole Proprietor?:No
Enumeration Date:2014-09-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT010188225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist