Healthcare Provider Details

I. General information

NPI: 1265449185
Provider Name (Legal Business Name): KIMBERLY A MATKEVICH OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 NE 39TH AVE
PORTLAND OR
97212-5322
US

IV. Provider business mailing address

3534 NE ALAMEDA ST
PORTLAND OR
97212-1806
US

V. Phone/Fax

Practice location:
  • Phone: 503-288-6181
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3182ATI
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: