Provider Demographics
NPI:1255429452
Name:STAUFFER, MATTHEW C (PT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:C
Last Name:STAUFFER
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 1:2296 COUNTRY DR
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-5315
Mailing Address - Country:US
Mailing Address - Phone:510-608-3614
Mailing Address - Fax:510-608-3691
Practice Address - Street 1:3905 BEACON AVE
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1405
Practice Address - Country:US
Practice Address - Phone:510-792-3555
Practice Address - Fax:510-797-5101
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33033225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT330330OtherBLUE SHIELD ID NUMBER