Provider Demographics
NPI:1700988433
Name:KRAEMER, MATTHEW D (PT)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:D
Last Name:KRAEMER
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 1:2549 ALPINE BLVD
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:CA
Mailing Address - Zip Code:91901-3950
Mailing Address - Country:US
Mailing Address - Phone:619-445-3168
Mailing Address - Fax:619-445-5368
Practice Address - Street 1:2549 ALPINE BLVD.
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:CA
Practice Address - Zip Code:91901-3950
Practice Address - Country:US
Practice Address - Phone:619-445-3168
Practice Address - Fax:619-445-5368
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT21100225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT00211000Medicaid
0PT21000OtherBLUE SHIELD COMMERCIAL
CAPT0211000Medicaid
0PT21000OtherBLUE SHIELD GOVERNMENT
CAPT0211000Medicaid
0PT21000OtherBLUE SHIELD COMMERCIAL