Provider Demographics
NPI:1194812099
Name:NELSON, MATTHEW L (OD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:L
Last Name:NELSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2257 SAMANTHA ST
Mailing Address - Street 2:APT 86
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-7413
Mailing Address - Country:US
Mailing Address - Phone:312-399-7694
Mailing Address - Fax:
Practice Address - Street 1:301 N BROADWAY
Practice Address - Street 2:HERITAGE SQUARE BUILDING
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-2557
Practice Address - Country:US
Practice Address - Phone:920-336-7700
Practice Address - Fax:920-338-1799
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1430152W00000X
WI3132-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist