Basic Information
| Provider Information | |||||||||
| NPI: | 1225664592 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | MATTHEW | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 E 4TH ST STE 440 | ||||||||
| Address2: | |||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620026241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184629818 | ||||||||
| FaxNumber: | 3147414947 | ||||||||
| Practice Location | |||||||||
| Address1: | 1545 NORTHWAY DR STE 120 | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563031941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202532441 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2020 | ||||||||
| LastUpdateDate: | 02/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 3672 | MN | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.