Provider Demographics
NPI:1518166610
Name:MOONEY, MATTHEW LUTES (OD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:LUTES
Last Name:MOONEY
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:PO BOX 691
Mailing Address - Street 2:
Mailing Address - City:MT WASHINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40047-0691
Mailing Address - Country:US
Mailing Address - Phone:502-593-7894
Mailing Address - Fax:
Practice Address - Street 1:223 DELAINA DR
Practice Address - Street 2:SUITE B
Practice Address - City:MT WASHINGTON
Practice Address - State:KY
Practice Address - Zip Code:40047-7148
Practice Address - Country:US
Practice Address - Phone:502-593-7894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-17
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1714DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100018320Medicaid
KY7100018320Medicaid
KYP000460890Medicare PIN