Basic Information
| Provider Information | |||||||||
| NPI: | 1043644040 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IRVIN | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 N 500 W | ||||||||
| Address2: | ATT: CREDENTIALING | ||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013548225 | ||||||||
| FaxNumber: | 8014180941 | ||||||||
| Practice Location | |||||||||
| Address1: | 7031 SW 62ND AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331434701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052847500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2013 | ||||||||
| LastUpdateDate: | 08/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | UO3788 | FL | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208100000X | OS13354 | FL | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208100000X | 11368809-1204 | UT | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.