Provider Demographics
NPI:1477172138
Name:EERNISSE, MATTHEW RICHARD (OD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RICHARD
Last Name:EERNISSE
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 1:2 FARM COLONY DR
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:PA
Mailing Address - Zip Code:16365-5203
Mailing Address - Country:US
Mailing Address - Phone:716-484-6700
Mailing Address - Fax:716-487-0166
Practice Address - Street 1:2 FARM COLONY DR
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:PA
Practice Address - Zip Code:16365-5203
Practice Address - Country:US
Practice Address - Phone:716-484-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-13
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV009265152W00000X
390200000X
PAOEG003709152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103797012Medicaid
NY06352987Medicaid