Provider Demographics
NPI:1245840370
Name:PAUL, MATT C (DPT)
Entity type:Individual
Prefix:
First Name:MATT
Middle Name:C
Last Name:PAUL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:ALBION
Mailing Address - State:IN
Mailing Address - Zip Code:46701-1500
Mailing Address - Country:US
Mailing Address - Phone:260-564-5850
Mailing Address - Fax:
Practice Address - Street 1:12722 TONKEL RD STE 102
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-8201
Practice Address - Country:US
Practice Address - Phone:260-739-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-04
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN05013789AOtherLICENSE
IN300041301Medicaid