Healthcare Provider Details

I. General information

NPI: 1912619339
Provider Name (Legal Business Name): MATTHEW JAMES HUBERTY OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2022
Last Update Date: 12/16/2022
Certification Date: 12/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14915 W MICHIGAN AVE
MARSHALL MI
49068-8504
US

IV. Provider business mailing address

10050 TUSCANY CT
PORTAGE MI
49024-9117
US

V. Phone/Fax

Practice location:
  • Phone: 269-781-9863
  • Fax:
Mailing address:
  • Phone: 269-548-6990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901005583
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: