Provider Demographics
NPI:1548818610
Name:KOCIUBA, MATTHEW R (DPT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:R
Last Name:KOCIUBA
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 1:411 HUKU LII PL STE 101
Mailing Address - Street 2:
Mailing Address - City:KIHEI
Mailing Address - State:HI
Mailing Address - Zip Code:96753-7062
Mailing Address - Country:US
Mailing Address - Phone:808-244-0077
Mailing Address - Fax:808-879-0177
Practice Address - Street 1:411 HUKU LII PL STE 101
Practice Address - Street 2:
Practice Address - City:KIHEI
Practice Address - State:HI
Practice Address - Zip Code:96753-7062
Practice Address - Country:US
Practice Address - Phone:808-244-0077
Practice Address - Fax:808-879-0177
Is Sole Proprietor?:No
Enumeration Date:2019-08-30
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI4895225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist