Provider Demographics
NPI:1295926228
Name:MATAYA PIETIG, AMANDA J (OD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:J
Last Name:MATAYA PIETIG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:311 N ANKENY BLVD
Mailing Address - Street 2:
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50023-1711
Mailing Address - Country:US
Mailing Address - Phone:515-964-1671
Mailing Address - Fax:515-964-1714
Practice Address - Street 1:311 N ANKENY BLVD
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-1711
Practice Address - Country:US
Practice Address - Phone:515-964-1671
Practice Address - Fax:515-964-1714
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-06
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002401152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA71726OtherBLUE CROSS
IA48179001OtherMEDICARE ID-TYPE UNSPECIF