Provider Demographics
NPI:1134119076
Name:BLEVINS, MATTHEW D (PT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:D
Last Name:BLEVINS
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 1:13020 N TELECOM PKWY
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33637-0925
Mailing Address - Country:US
Mailing Address - Phone:813-978-9700
Mailing Address - Fax:813-972-5055
Practice Address - Street 1:13020 N TELECOM PKWY
Practice Address - Street 2:
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33637-0925
Practice Address - Country:US
Practice Address - Phone:813-978-9700
Practice Address - Fax:813-972-5055
Is Sole Proprietor?:No
Enumeration Date:2005-10-23
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070012903225100000X
FLPT224802251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00733182OtherRAILROAD MEDICARE
IL070012903Medicaid
IL070012903Medicaid
ILQ00127Medicare UPIN
FLBF729ZMedicare PIN