Provider Demographics
NPI:1427807437
Name:SELECMAN, CONNER MATTHEW (OD)
Entity type:Individual
Prefix:
First Name:CONNER
Middle Name:MATTHEW
Last Name:SELECMAN
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 1:234 FRYE TOWN LN
Mailing Address - Street 2:
Mailing Address - City:SALTVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24370-3137
Mailing Address - Country:US
Mailing Address - Phone:276-706-7674
Mailing Address - Fax:
Practice Address - Street 1:1128 N MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:VA
Practice Address - Zip Code:24354-4299
Practice Address - Country:US
Practice Address - Phone:276-783-6131
Practice Address - Fax:276-783-1953
Is Sole Proprietor?:No
Enumeration Date:2024-05-14
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA390200000X
VA0618003412152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program