Provider Demographics
NPI:1003269721
Name:KREWER, MATTHEW (OD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:KREWER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 E SAN MARNAN DR
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-5611
Mailing Address - Country:US
Mailing Address - Phone:319-233-2020
Mailing Address - Fax:
Practice Address - Street 1:909 E SAN MARNAN DR
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702-5611
Practice Address - Country:US
Practice Address - Phone:319-233-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-18
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60679692152W00000X
IA097765152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1003269721Medicaid
WAP01707746OtherRR PTAN WVH
WAP01707746OtherRR PTAN WVH