Provider Demographics
NPI:1215168141
Name:SIEMER, MATTHEW A (OD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:A
Last Name:SIEMER
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 1:2301 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66048-4214
Mailing Address - Country:US
Mailing Address - Phone:913-682-2929
Mailing Address - Fax:913-682-2999
Practice Address - Street 1:21 N 12TH ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66102-5161
Practice Address - Country:US
Practice Address - Phone:913-342-4405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-27
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7447TG152W00000X
KS1901152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1901OtherKANSAS LICENSE