Provider Demographics
NPI:1649330390
Name:MODDERNO, MATTHEW J (OD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:J
Last Name:MODDERNO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:138 NAHATAN ST.
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02062
Mailing Address - Country:US
Mailing Address - Phone:781-255-1505
Mailing Address - Fax:781-255-1507
Practice Address - Street 1:138 NAHATAN ST.
Practice Address - Street 2:
Practice Address - City:NORWOOD
Practice Address - State:MA
Practice Address - Zip Code:02062
Practice Address - Country:US
Practice Address - Phone:781-255-1505
Practice Address - Fax:781-255-1507
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4353152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAV01297Medicare UPIN