Provider Demographics
NPI:1215911417
Name:MATOBA, ROBERT KEN (OD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:KEN
Last Name:MATOBA
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 1:200 UNION BLVD
Mailing Address - Street 2:SUITE 415
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80228-1830
Mailing Address - Country:US
Mailing Address - Phone:303-988-2777
Mailing Address - Fax:303-988-8855
Practice Address - Street 1:200 UNION BLVD
Practice Address - Street 2:SUITE 415
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80228-1830
Practice Address - Country:US
Practice Address - Phone:303-988-2777
Practice Address - Fax:303-988-8855
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-01
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT1378152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO79637256Medicaid
COCO303184OtherMEDICARE PTAN
COT60451Medicare UPIN
CO79637256Medicaid