Provider Demographics
NPI:1811242365
Name:DUPONT, MATTHEW RICHARD (DPT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RICHARD
Last Name:DUPONT
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 1:1106 WALNUT ST STE 110
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-2416
Mailing Address - Country:US
Mailing Address - Phone:805-788-0805
Mailing Address - Fax:805-788-0845
Practice Address - Street 1:1510 W BRANCH ST
Practice Address - Street 2:
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420-1817
Practice Address - Country:US
Practice Address - Phone:805-489-7912
Practice Address - Fax:805-489-9697
Is Sole Proprietor?:No
Enumeration Date:2012-07-20
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60669915225100000X
MA20067225100000X
CA292545225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist