Provider Demographics
NPI:1982631107
Name:SCULLAWL, MATTHEW KORY (OD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:KORY
Last Name:SCULLAWL
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 1:213 W OLIVE ST
Mailing Address - Street 2:STE 101
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65806-1301
Mailing Address - Country:US
Mailing Address - Phone:417-862-3937
Mailing Address - Fax:417-862-3936
Practice Address - Street 1:213 W OLIVE ST
Practice Address - Street 2:STE 101
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65806-1301
Practice Address - Country:US
Practice Address - Phone:417-862-3937
Practice Address - Fax:417-862-3936
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006036228152W00000X
OK2403152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200066910AMedicaid
OKU98129Medicare UPIN
OK200066910AMedicaid