Basic Information
| Provider Information | |||||||||
| NPI: | 1528163300 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MATTAX NEU PRATER EYE CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1265 E PRIMROSE ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658044278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178863937 | ||||||||
| FaxNumber: | 4178861285 | ||||||||
| Practice Location | |||||||||
| Address1: | 430 N JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 655362742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178863937 | ||||||||
| FaxNumber: | 4178861285 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 05/05/2016 | ||||||||
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| AuthorizedOfficialLastName: | MATTAX | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4178863937 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 207W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | CI7182 | 01 | MO | RAILROAD MEDICARE PART B | OTHER | 505886200 | 05 | MO | MEDICAID |