Provider Demographics
NPI:1043053481
Name:MOE, MATTHEW (OD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:MOE
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 1:5501 E 18TH ST APT 444
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57110-2841
Mailing Address - Country:US
Mailing Address - Phone:605-521-9936
Mailing Address - Fax:
Practice Address - Street 1:2414 S LOUISE AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57106-4318
Practice Address - Country:US
Practice Address - Phone:605-362-9255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-14
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD809152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist