=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780082644
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW IAN SELTZER DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2014
-----------------------------------------------------
Last Update Date | 06/30/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1384 BROADWAY STE 606
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10018-6108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-896-3821
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2516 30TH DR APT 2F
-----------------------------------------------------
City | ASTORIA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11102-2733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-896-3821
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 038508-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------