Provider Demographics
NPI:1235340522
Name:APPENZELLER, MATTHEW FOREST (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:FOREST
Last Name:APPENZELLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4353 DODGE ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68131-2709
Mailing Address - Country:US
Mailing Address - Phone:402-552-2020
Mailing Address - Fax:402-552-2367
Practice Address - Street 1:4353 DODGE ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68131-2709
Practice Address - Country:US
Practice Address - Phone:402-552-2020
Practice Address - Fax:402-552-2367
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA42480207W00000X
NE28330207WX0107X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2837845Medicaid
IN200900370Medicaid
OH4234271Medicare PIN
OH4234271Medicare PIN