Healthcare Provider Details

I. General information

NPI: 1073012803
Provider Name (Legal Business Name): MATTHEW DONALDSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2018
Last Update Date: 02/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 FRANKLIN CORNER RD
LAWRENCEVILLE NJ
08648-2586
US

IV. Provider business mailing address

304 W PARK BLVD
HADDONFIELD NJ
08033-2963
US

V. Phone/Fax

Practice location:
  • Phone: 609-912-0440
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA01764500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: