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General NPI Number Information
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NPI Number | 1457404311
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Entity Type | Individual
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Provider Name | GLENN T MATOBA OD
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Gender | Male
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Dates
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Enumeration Date | 01/22/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 14500 W COLFAX AVE
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City | LAKEWOOD
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State | CO
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Zip | 80401-3203
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Country | US
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Telephone | 303-273-9953
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Fax | 303-273-9955
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Provider Business Mailing Address
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Address Line | 16581 W ELLSWORTH AVE
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City | GOLDEN
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State | CO
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Zip | 80401-6540
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Country | US
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Telephone | 303-277-1349
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Fax |
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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 | CO1484
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License Number State | CO
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 9539
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License Number State | CA
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