Healthcare Provider Details

I. General information

NPI: 1023674488
Provider Name (Legal Business Name): MATTHEW TESTA OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2019
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 W HIGHWAY 92 STE 3
WILLIAMSBURG KY
40769-1936
US

IV. Provider business mailing address

PO BOX 296
FERGUSON KY
42533-0296
US

V. Phone/Fax

Practice location:
  • Phone: 606-549-0464
  • Fax: 606-532-1773
Mailing address:
  • Phone: 606-492-2211
  • Fax: 606-676-0873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3562
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: