Provider Demographics
NPI:1902427693
Name:POTTER, MATTHEW (DPT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:POTTER
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 1:618 MARISOL DR
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-5356
Mailing Address - Country:US
Mailing Address - Phone:321-525-0612
Mailing Address - Fax:
Practice Address - Street 1:618 MARISOL DR
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-5356
Practice Address - Country:US
Practice Address - Phone:321-525-0612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-04
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL34853225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist