Provider Demographics
NPI:1023775459
Name:GOODFELLOW, MATTHEW B (CDT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:B
Last Name:GOODFELLOW
Suffix:
Gender:M
Credentials:CDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2633 11 MILE RD NW
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:MI
Mailing Address - Zip Code:49345-9751
Mailing Address - Country:US
Mailing Address - Phone:616-773-8339
Mailing Address - Fax:
Practice Address - Street 1:2633 11 MILE RD NW
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:MI
Practice Address - Zip Code:49345-9751
Practice Address - Country:US
Practice Address - Phone:616-773-8339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-19
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist