Provider Demographics
NPI:1417022773
Name:BERARDI, MATTHEW GLEN (OD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:GLEN
Last Name:BERARDI
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 1:3208 HUSKY HWY
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:26571-8122
Mailing Address - Country:US
Mailing Address - Phone:304-825-6364
Mailing Address - Fax:304-825-6750
Practice Address - Street 1:3208 HUSKY HWY
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:WV
Practice Address - Zip Code:26571-8122
Practice Address - Country:US
Practice Address - Phone:304-825-6364
Practice Address - Fax:304-825-6750
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV830-D152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810007303Medicaid
T32435Medicare UPIN