Provider Demographics
NPI:1780274613
Name:DOORE, MATTHEW R (OD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:R
Last Name:DOORE
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 1:901 E 86TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-1807
Mailing Address - Country:US
Mailing Address - Phone:317-844-5500
Mailing Address - Fax:317-208-2248
Practice Address - Street 1:901 E 86TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-1807
Practice Address - Country:US
Practice Address - Phone:317-844-5500
Practice Address - Fax:317-208-2248
Is Sole Proprietor?:No
Enumeration Date:2021-01-25
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA107206152W00000X
IN18004373A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA107206OtherSTATE LICENSE
IN300080058Medicaid