Provider Demographics
NPI:1952639916
Name:MATIJEVICH, ROBERT ALLEN (PT)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:ALLEN
Last Name:MATIJEVICH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 S SIZER AVE STE B
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37760-2436
Mailing Address - Country:US
Mailing Address - Phone:865-246-8090
Mailing Address - Fax:
Practice Address - Street 1:1405 S SIZER AVE STE B
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37760-2436
Practice Address - Country:US
Practice Address - Phone:865-246-8090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-02
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT0000001151225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist