Provider Demographics
NPI:1477172138
Name:EERNISSE, MATTHEW RICHARD (OD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RICHARD
Last Name:EERNISSE
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 1:1700 OLD GATESBURG RD STE 300
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16803-2276
Mailing Address - Country:US
Mailing Address - Phone:814-234-1002
Mailing Address - Fax:014-234-6251
Practice Address - Street 1:1700 OLD GATESBURG RD STE 300
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16803-2276
Practice Address - Country:US
Practice Address - Phone:814-234-1002
Practice Address - Fax:814-234-6251
Is Sole Proprietor?:No
Enumeration Date:2020-04-13
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG003709152WC0802X, 152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103797012Medicaid
NY06352987Medicaid