Provider Demographics
NPI:1023120755
Name:WANER, MATTHEW ROBERT (OD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:ROBERT
Last Name:WANER
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 1:300 HWY 24
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28557-2551
Mailing Address - Country:US
Mailing Address - Phone:252-622-4358
Mailing Address - Fax:252-622-4359
Practice Address - Street 1:300 HWY 24
Practice Address - Street 2:
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557-2551
Practice Address - Country:US
Practice Address - Phone:252-622-4358
Practice Address - Fax:252-622-4359
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2009-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2053152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist