Provider Demographics
NPI:1124079041
Name:MERRELL, MATT G (OD)
Entity type:Individual
Prefix:
First Name:MATT
Middle Name:G
Last Name:MERRELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526H SHOUP AVE W.
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5050
Mailing Address - Country:US
Mailing Address - Phone:208-733-2400
Mailing Address - Fax:208-734-0343
Practice Address - Street 1:526H SHOUP AVE W.
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5050
Practice Address - Country:US
Practice Address - Phone:208-733-2400
Practice Address - Fax:208-734-0343
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP878152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000309200Medicaid
ID000309200Medicaid
IDU47768Medicare UPIN