Provider Demographics
NPI:1669779195
Name:BARNETT, MATTHEW KEENAN
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:KEENAN
Last Name:BARNETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 KANSAS CITY ST
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-3636
Mailing Address - Country:US
Mailing Address - Phone:605-348-2323
Mailing Address - Fax:605-348-6694
Practice Address - Street 1:409 KANSAS CITY ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-3636
Practice Address - Country:US
Practice Address - Phone:605-348-2323
Practice Address - Fax:605-348-6694
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-18
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0003034152W00000X
SD750152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty