Provider Demographics
NPI:1801596994
Name:MANDLE, MATTHEW COLIN (DPT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:COLIN
Last Name:MANDLE
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 1:105 TAUNTON DR
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:ME
Mailing Address - Zip Code:04664-3009
Mailing Address - Country:US
Mailing Address - Phone:201-962-6574
Mailing Address - Fax:
Practice Address - Street 1:11 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MACHIAS
Practice Address - State:ME
Practice Address - Zip Code:04654-3325
Practice Address - Country:US
Practice Address - Phone:207-255-3356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT6458208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation