Healthcare Provider Details

I. General information

NPI: 1477172138
Provider Name (Legal Business Name): MATTHEW RICHARD EERNISSE OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2020
Last Update Date: 06/16/2025
Certification Date: 06/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 OLD GATESBURG RD STE 300
STATE COLLEGE PA
16803-2276
US

IV. Provider business mailing address

1700 OLD GATESBURG RD STE 300
STATE COLLEGE PA
16803-2276
US

V. Phone/Fax

Practice location:
  • Phone: 814-234-1002
  • Fax: 814-234-6251
Mailing address:
  • Phone: 814-234-1002
  • Fax: 14-234-6251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOEG003709
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG003709
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier103797012
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: