Basic Information
Provider Information
NPI: 1578783700
EntityType: 2
ReplacementNPI:  
OrganizationName: MATTAX NEU PRATER EYE CENTER, INC.
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
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OtherCredential:  
OtherLastNameType:  
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: 4175882400
FaxNumber: 4175882059
Other Information
ProviderEnumerationDate: 04/30/2007
LastUpdateDate: 03/24/2008
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: MATTAX
AuthorizedOfficialFirstName: JAMES
AuthorizedOfficialMiddleName: B
AuthorizedOfficialTitleorPosition: CORPORATE PRESIDENT
AuthorizedOfficialTelephone: 4178863937
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix: JR.
AuthorizedOfficialCredential: M.D.
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
332H00000X  Y SuppliersEyewear Supplier (Equipment, not the service) 

ID Information
IDTypeStateIssuerDescription
32588620805MO MEDICAID


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