MEDICARE: DR. MATTHEW LOGAN WAMPLER OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OPT9619T	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	SD0096190	OTHER	CA	BLUE CROSS OF CA

General Provider Information

NPI Number	:	1134190689
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MATTHEW LOGAN WAMPLER OD

Provider Business Mailing Address
First Line	:	2101 STONE BLVD
Second Line	:	STE. 150
City	:	WEST SACRAMENTO
State	:	CA
Zip	:	95691-4044
Country	:	US
Telephone Number	:	916-372-3090
Fax Number	:	916-372-8055

Provider Business Practice Location Address
First Line	:	2101 STONE BLVD
Second Line	:	STE. 150
City	:	WEST SACRAMENTO
State	:	CA
Zip	:	95691-4044
Country	:	US
Telephone Number	:	916-372-3090
Fax Number	:	916-372-8055

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/31/2006
Last Update Date	:	01/17/2008

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