Provider Demographics
NPI:1992713309
Name:NICHOLSON, MATTHEW CLARK (OD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:CLARK
Last Name:NICHOLSON
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 1:352 BROWN BLVD
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-2458
Mailing Address - Country:US
Mailing Address - Phone:815-932-2020
Mailing Address - Fax:815-937-0060
Practice Address - Street 1:352 BROWN BLVD
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-2458
Practice Address - Country:US
Practice Address - Phone:815-932-2020
Practice Address - Fax:815-937-0060
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008729152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046008729Medicaid
IL346001680OtherCONTROLLED SUBSTANCE
IL346001680OtherCONTROLLED SUBSTANCE
ILU53248Medicare UPIN
IL046008729Medicaid