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General NPI Number Information
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NPI Number | 1366411969
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Entity Type | Individual
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Provider Name | MATTHEW J. WOODYARD O.D.
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Gender | Male
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Dates
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Enumeration Date | 03/16/2006
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Last Update Date | 12/19/2012
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Provider Practice Location Address
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Address Line | 11477 OLIVE BLVD
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City | CREVE COEUR
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State | MO
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Zip | 63141-7108
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Country | US
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Telephone | 314-567-3884
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Fax | 800-432-6004
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Provider Business Mailing Address
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Address Line | 211 E BROADWAY
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City | ALTON
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State | IL
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Zip | 62002-6220
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Country | US
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Telephone | 314-567-3884
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Fax | 800-432-6004
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2003017104
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License Number State | MO
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