Provider Demographics
NPI:1619064532
Name:CRONISTER, MATTHEW ROBERT (OD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:ROBERT
Last Name:CRONISTER
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 1:8619 HIGHWAY NN
Mailing Address - Street 2:
Mailing Address - City:NEOSHO
Mailing Address - State:MO
Mailing Address - Zip Code:64850-7133
Mailing Address - Country:US
Mailing Address - Phone:417-206-0667
Mailing Address - Fax:
Practice Address - Street 1:2639 E 32ND ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-4320
Practice Address - Country:US
Practice Address - Phone:417-659-9494
Practice Address - Fax:417-659-9499
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004004460152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOV05901Medicare UPIN