=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689272502
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HAYDEN MATZ OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2020
-----------------------------------------------------
Last Update Date | 11/15/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 251 N SAWYER ST
-----------------------------------------------------
City | OSHKOSH
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54902-4251
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-235-5530
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2225 SOFTWIND RD
-----------------------------------------------------
City | NEENAH
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54956-3466
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-312-3407
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 3862-35
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 3614
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------