Provider Demographics
NPI:1326294240
Name:MARVIN J. MATSON OD, PC
Entity Type:Organization
Organization Name:MARVIN J. MATSON OD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:MATSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:517-882-0202
Mailing Address - Street 1:5224 S CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911-3862
Mailing Address - Country:US
Mailing Address - Phone:517-882-0202
Mailing Address - Fax:517-882-0980
Practice Address - Street 1:5224 S CEDAR ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911-3862
Practice Address - Country:US
Practice Address - Phone:517-882-0202
Practice Address - Fax:517-882-0980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-12
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002636152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6145530001Medicare NSC