Provider Demographics
NPI:1881739563
Name:VERNON, MATTHEW HOWARD (OPTICIAN)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:HOWARD
Last Name:VERNON
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1285 SO US #1
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955
Mailing Address - Country:US
Mailing Address - Phone:321-631-2811
Mailing Address - Fax:321-631-0624
Practice Address - Street 1:1285 SO US #1
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955
Practice Address - Country:US
Practice Address - Phone:321-631-2811
Practice Address - Fax:321-631-0624
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1365156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0877920001Medicare ID - Type Unspecified