Provider Demographics
NPI:1114082633
Name:VANOVER, MATTHEW (OD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:VANOVER
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 1:1515 S FORREST HEIGHTS AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65809-2318
Mailing Address - Country:US
Mailing Address - Phone:417-693-9512
Mailing Address - Fax:417-512-8855
Practice Address - Street 1:279 N EASTGATE AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802
Practice Address - Country:US
Practice Address - Phone:417-512-8954
Practice Address - Fax:417-512-8855
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002030098152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist