Provider Demographics
NPI:1801832225
Name:INGRAM, MATTHEW ROSSLAND (OD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ROSSLAND
Last Name:INGRAM
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 1:418 GRAND PARK DR
Mailing Address - Street 2:SUITE 315
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26105-4000
Mailing Address - Country:US
Mailing Address - Phone:304-428-3500
Mailing Address - Fax:304-422-7900
Practice Address - Street 1:418 GRAND PARK DR
Practice Address - Street 2:SUITE 315
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26105-4000
Practice Address - Country:US
Practice Address - Phone:304-428-3500
Practice Address - Fax:304-422-7900
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHT2470152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001772033OtherMOUNTAIN STATE BLUE CROSS
OH2590414Medicaid
0707695OtherCIGNA
7395753OtherAETNA
P00269537OtherRAILROAD MEDICARE
000000384708OtherANTHEM BLUE CROSS
WV3810003387Medicaid
WV001772033OtherMOUNTAIN STATE BLUE CROSS
000000384708OtherANTHEM BLUE CROSS
OH2590414Medicaid