Provider Demographics
NPI:1083065122
Name:BOSWELL, MATTHEW THOMAS (OD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:THOMAS
Last Name:BOSWELL
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 1:3000 E 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:KS
Mailing Address - Zip Code:67156-3439
Mailing Address - Country:US
Mailing Address - Phone:620-221-2015
Mailing Address - Fax:620-221-2015
Practice Address - Street 1:3000 E 9TH AVE
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:KS
Practice Address - Zip Code:67156-3439
Practice Address - Country:US
Practice Address - Phone:620-221-2492
Practice Address - Fax:620-221-2015
Is Sole Proprietor?:No
Enumeration Date:2016-06-30
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2022152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS30004639110001Medicaid