Provider Demographics
NPI:1487648952
Name:KENT, MATTHEW E (OD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:E
Last Name:KENT
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 1:520 N GREENWOOD STREET
Mailing Address - Street 2:
Mailing Address - City:SHOSHONE
Mailing Address - State:ID
Mailing Address - Zip Code:83352
Mailing Address - Country:US
Mailing Address - Phone:208-537-2020
Mailing Address - Fax:208-537-2010
Practice Address - Street 1:520 N GREENWOOD STREET
Practice Address - Street 2:
Practice Address - City:SHOSHONE
Practice Address - State:ID
Practice Address - Zip Code:83352
Practice Address - Country:US
Practice Address - Phone:208-537-2020
Practice Address - Fax:208-537-2010
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100083152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807212200Medicaid
IDV06021Medicare ID - Type Unspecified