Provider Demographics
NPI:1255720686
Name:KIRSTEN, MATTHEW CHARLES (DPT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:CHARLES
Last Name:KIRSTEN
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 1:200 NEWPORT CENTER DR
Mailing Address - Street 2:#213
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7501
Mailing Address - Country:US
Mailing Address - Phone:949-644-1322
Mailing Address - Fax:949-644-0316
Practice Address - Street 1:26302 LA PAZ RD
Practice Address - Street 2:SUITE 105
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-5313
Practice Address - Country:US
Practice Address - Phone:949-206-1700
Practice Address - Fax:949-206-1800
Is Sole Proprietor?:No
Enumeration Date:2015-01-22
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42121225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPENDINGOtherMEDICARE PTAN