Provider Demographics
NPI:1427113208
Name:CAPO, MATTHEW THOMAS (PT)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:THOMAS
Last Name:CAPO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6424 KOME DR
Mailing Address - Street 2:
Mailing Address - City:DIAMONDHEAD
Mailing Address - State:MS
Mailing Address - Zip Code:39525-3816
Mailing Address - Country:US
Mailing Address - Phone:228-255-6644
Mailing Address - Fax:
Practice Address - Street 1:833 HIGHWAY 90 STE 2
Practice Address - Street 2:
Practice Address - City:BAY ST LOUIS
Practice Address - State:MS
Practice Address - Zip Code:39520-1601
Practice Address - Country:US
Practice Address - Phone:228-463-9030
Practice Address - Fax:228-463-0103
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT1744225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00119094Medicaid