Healthcare Provider Details

I. General information

NPI: 1992442438
Provider Name (Legal Business Name): MATTHEW JAY HEPWORTH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2022
Last Update Date: 07/12/2022
Certification Date: 07/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3192 WILLOW CREEK RD
PRESCOTT AZ
86301-6610
US

IV. Provider business mailing address

19841 N 68TH DR
GLENDALE AZ
85308-5593
US

V. Phone/Fax

Practice location:
  • Phone: 928-445-1234
  • Fax:
Mailing address:
  • Phone: 801-808-4832
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT-002603
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: