Provider Demographics
NPI:1134469406
Name:SULLIVAN, MATHEW BYRON (PT)
Entity type:Individual
Prefix:DR
First Name:MATHEW
Middle Name:BYRON
Last Name:SULLIVAN
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 1:5152 KATELLA AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-2817
Mailing Address - Country:US
Mailing Address - Phone:562-431-6004
Mailing Address - Fax:562-431-9854
Practice Address - Street 1:5152 KATELLA AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-2817
Practice Address - Country:US
Practice Address - Phone:562-431-6004
Practice Address - Fax:562-431-9854
Is Sole Proprietor?:No
Enumeration Date:2013-02-25
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28874225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PT28874OtherPT LICENSE