Provider Demographics
NPI:1588990295
Name:WATSON, MATTHEW L (OD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:L
Last Name:WATSON
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 1:4523 N 3150 E
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:UT
Mailing Address - Zip Code:84310-9779
Mailing Address - Country:US
Mailing Address - Phone:801-791-3345
Mailing Address - Fax:
Practice Address - Street 1:6191 S STATE ST STE 301
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-7270
Practice Address - Country:US
Practice Address - Phone:801-268-0408
Practice Address - Fax:801-261-3091
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-30
Last Update Date:2017-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7370813-9934152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty