Provider Demographics
NPI:1760604854
Name:KISABETH, MATTHEW THOMAS (OD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:THOMAS
Last Name:KISABETH
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 1513
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48804
Mailing Address - Country:US
Mailing Address - Phone:989-330-5505
Mailing Address - Fax:
Practice Address - Street 1:5650 BAY ROAD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604
Practice Address - Country:US
Practice Address - Phone:989-790-8937
Practice Address - Fax:989-790-8940
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004289152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U87720Medicare UPIN
4062421Medicare ID - Type Unspecified