Basic Information
| Provider Information | |||||||||
| NPI: | 1518098193 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JEFFS | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 906 SHORE DR | ||||||||
| Address2: | |||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320865748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048250540 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 ORTHOPAEDIC PL | ||||||||
| Address2: | |||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320864202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048250540 | ||||||||
| FaxNumber: | 9042091055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 02/11/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | PT7191 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
ID Information
| ID | Type | State | Issuer | Description | 1174540001 | 01 | FL | DMERC | OTHER | PT 7191 | 01 | FL | FLORDIA LICENSE | OTHER |