Provider Demographics
NPI:1457404311
Name:MATOBA, GLENN T (OD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:T
Last Name:MATOBA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:16581 W ELLSWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:GOLDEN
Mailing Address - State:CO
Mailing Address - Zip Code:80401-6540
Mailing Address - Country:US
Mailing Address - Phone:303-277-1349
Mailing Address - Fax:
Practice Address - Street 1:14500 W COLFAX AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80401-3203
Practice Address - Country:US
Practice Address - Phone:303-273-9953
Practice Address - Fax:303-273-9955
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO1484152W00000X
CA9539152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist