Provider Demographics
NPI:1750872768
Name:LANGWORTHY, MATTHEW
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:LANGWORTHY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3760 CONVOY ST STE 101
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-3743
Mailing Address - Country:US
Mailing Address - Phone:888-208-8526
Mailing Address - Fax:
Practice Address - Street 1:3405 KENYON ST STE 212
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110
Practice Address - Country:US
Practice Address - Phone:619-523-9874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-24
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT294466225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist