Provider Demographics
NPI:1366735243
Name:MANRY, MATTHEW WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:WILLIAM
Last Name:MANRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1945 CEI DR
Mailing Address - Street 2:
Mailing Address - City:BLUE ASH
Mailing Address - State:OH
Mailing Address - Zip Code:45242-5664
Mailing Address - Country:US
Mailing Address - Phone:513-569-3741
Mailing Address - Fax:513-569-3941
Practice Address - Street 1:1400 DRY CREEK DR
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80503
Practice Address - Country:US
Practice Address - Phone:303-772-3300
Practice Address - Fax:303-682-3380
Is Sole Proprietor?:No
Enumeration Date:2011-05-25
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0060309207WX0107X
MI4301098358207W00000X, 390200000X
KY49077207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000163774Medicaid
OH0167631Medicaid
IN201357960Medicaid
OH000001010988OtherANTHEM/BCBS
OHH471410Medicare PIN