Provider Demographics
NPI:1144718222
Name:GUNDLACH, MATTHEW (PT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:GUNDLACH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 378
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44871-0378
Mailing Address - Country:US
Mailing Address - Phone:419-609-1112
Mailing Address - Fax:419-502-3511
Practice Address - Street 1:2500 W STRUB RD STE 150
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870
Practice Address - Country:US
Practice Address - Phone:419-626-4162
Practice Address - Fax:419-626-1268
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-25
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH000137331225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPENDINGMedicaid