Provider Demographics
NPI:1174866966
Name:OPOLKA, MATTHEW J (PT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:OPOLKA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7210
Mailing Address - Fax:920-445-7238
Practice Address - Street 1:2714 RIVERVIEW DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-6715
Practice Address - Country:US
Practice Address - Phone:920-430-4760
Practice Address - Fax:920-430-4774
Is Sole Proprietor?:No
Enumeration Date:2013-04-01
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12243-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI12243-24OtherLICENSE