Provider Demographics
NPI:1194782961
Name:DEWALL, MATTHEW RAY (MPT CSCS)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RAY
Last Name:DEWALL
Suffix:
Gender:M
Credentials:MPT CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 461
Mailing Address - Street 2:
Mailing Address - City:NEVADA
Mailing Address - State:IA
Mailing Address - Zip Code:50201-0461
Mailing Address - Country:US
Mailing Address - Phone:515-382-3366
Mailing Address - Fax:515-382-1576
Practice Address - Street 1:1507 NORTH 1ST ST
Practice Address - Street 2:
Practice Address - City:INDIANOLA
Practice Address - State:IA
Practice Address - Zip Code:50125
Practice Address - Country:US
Practice Address - Phone:515-382-3366
Practice Address - Fax:515-382-1576
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03373225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA36592OtherBCBS IND
IA46363OtherBCBS GR & MADRID
IA46364OtherBCBS AH