Healthcare Provider Details

I. General information

NPI: 1164105979
Provider Name (Legal Business Name): MATTHEW TJANDRA PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2023
Last Update Date: 08/11/2023
Certification Date: 08/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2135 WESTCLIFF DR STE 203
NEWPORT BEACH CA
92660-5543
US

IV. Provider business mailing address

126 STEPPING STONE
IRVINE CA
92603-4244
US

V. Phone/Fax

Practice location:
  • Phone: 949-299-0297
  • Fax:
Mailing address:
  • Phone: 626-227-4829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number304539
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: