Provider Demographics
NPI:1679648653
Name:MATUSIEWICZ, DAVID THOMAS (OD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:THOMAS
Last Name:MATUSIEWICZ
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 1:317 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19711-7152
Mailing Address - Country:US
Mailing Address - Phone:302-737-5777
Mailing Address - Fax:302-737-0142
Practice Address - Street 1:317 E MAIN ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19711-7152
Practice Address - Country:US
Practice Address - Phone:302-737-5777
Practice Address - Fax:302-737-0142
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEI3-0001202152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE510362254 0001OtherCIGNA HEALTHCARE
DE510362254 19711 A001OtherTRICARE NORTH REGION
DE0000594145Medicaid
DE0483709OtherAETNA HMO
DE4517150OtherAETNA, INC.
DE27415OtherCOVENTRY HEALTH CARE DE
DE510362254 0001OtherCIGNA HEALTHCARE
DE00A110D71Medicare ID - Type Unspecified