Provider Demographics
NPI:1386625283
Name:OPPEGAARD, MATTHEW S (OD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:S
Last Name:OPPEGAARD
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 1:78 NOVATO ST
Mailing Address - Street 2:#12
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-4685
Mailing Address - Country:US
Mailing Address - Phone:415-454-8013
Mailing Address - Fax:415-454-8014
Practice Address - Street 1:78 NOVATO ST
Practice Address - Street 2:#12
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-4685
Practice Address - Country:US
Practice Address - Phone:415-454-8013
Practice Address - Fax:415-454-8014
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAT10545152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU58775Medicare UPIN
CASD0105450Medicare ID - Type UnspecifiedMEDICARRE/MEDICAID