Provider Demographics
NPI:1366411969
Name:WOODYARD, MATTHEW J (OD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:J
Last Name:WOODYARD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:211 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6220
Mailing Address - Country:US
Mailing Address - Phone:314-567-3884
Mailing Address - Fax:800-432-6004
Practice Address - Street 1:11477 OLIVE BLVD
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-7108
Practice Address - Country:US
Practice Address - Phone:314-567-3884
Practice Address - Fax:800-432-6004
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003017104152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1962644732OtherGROUP NPI
211205OtherCOLE
179523OtherBLUE CROSS BLUE SHIELD MO
MO1295737294OtherGROUP NPI
MO45351OtherHEALTHCARE USA
674993OtherHEALTHLINK
MOMA2784OtherGROUP PTAN
MO1366411969OtherINDIVIDUAL NPI
MO1366411969Medicaid
26004OtherOPTICARE MED. COMPLETE
MO319024600Medicaid
51675OtherDAVIS VISION
MOP00403049OtherRR MEDICARE
MO319024618Medicaid
MO990301722OtherMEDICARE PART B
MO7104OtherEYEMED
MO319024618Medicaid
MO1295737294OtherGROUP NPI
MO319024600Medicaid