Provider Demographics
NPI:1124787775
Name:KOEPKE, MATTHEW EDWARD (DPT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:EDWARD
Last Name:KOEPKE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4222 DUCK CREEK WAY
Mailing Address - Street 2:
Mailing Address - City:ELLENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34222-7278
Mailing Address - Country:US
Mailing Address - Phone:734-855-5050
Mailing Address - Fax:
Practice Address - Street 1:1401 8TH AVE W STE A
Practice Address - Street 2:
Practice Address - City:PALMETTO
Practice Address - State:FL
Practice Address - Zip Code:34221-3119
Practice Address - Country:US
Practice Address - Phone:194-172-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-10
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL38168225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist