Healthcare Provider Details

I. General information

NPI: 1013204890
Provider Name (Legal Business Name): MATTHEW LUKE WILLIS O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2011
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 OLSON DR
PAPILLION NE
68046-2960
US

IV. Provider business mailing address

2514 W BROADWAY
COUNCIL BLUFFS IA
51501-3509
US

V. Phone/Fax

Practice location:
  • Phone: 402-504-4257
  • Fax:
Mailing address:
  • Phone: 712-322-3097
  • Fax: 712-322-4130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number002558
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1380
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: