Healthcare Provider Details

I. General information

NPI: 1114082633
Provider Name (Legal Business Name): MATTHEW VANOVER OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 07/30/2021
Certification Date: 06/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

279 N EASTGATE AVE
SPRINGFIELD MO
65802
US

IV. Provider business mailing address

1515 S FORREST HEIGHTS AVE
SPRINGFIELD MO
65809-2318
US

V. Phone/Fax

Practice location:
  • Phone: 417-512-8954
  • Fax: 417-512-8855
Mailing address:
  • Phone: 417-693-9512
  • Fax: 417-512-8855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2002030098
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: