Provider Demographics
NPI:1831397801
Name:EARHART, MATTHEW WALDEN (OD, MED)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:WALDEN
Last Name:EARHART
Suffix:
Gender:M
Credentials:OD, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SEE VEE LN
Mailing Address - Street 2:
Mailing Address - City:BISHOP
Mailing Address - State:CA
Mailing Address - Zip Code:93514-8130
Mailing Address - Country:US
Mailing Address - Phone:760-873-3611
Mailing Address - Fax:760-873-3612
Practice Address - Street 1:250 N SEE VEE LN
Practice Address - Street 2:
Practice Address - City:BISHOP
Practice Address - State:CA
Practice Address - Zip Code:93514-8130
Practice Address - Country:US
Practice Address - Phone:760-873-3611
Practice Address - Fax:760-873-3612
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13441 TLG152W00000X, 152W00000X
NV950152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACN337YOtherMEDICARE PTAN
CACN337ZOtherMEDICARE TPAN