Provider Demographics
NPI:1003904483
Name:MAHONEY, ROBERT G (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:G
Last Name:MAHONEY
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 1:4304 TAYLOR AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53405-4641
Mailing Address - Country:US
Mailing Address - Phone:262-404-5001
Mailing Address - Fax:
Practice Address - Street 1:4304 TAYLOR AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53405-4641
Practice Address - Country:US
Practice Address - Phone:262-404-5001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2190-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38532000Medicaid
207481OtherEYEMED VISION NO.
207481OtherEYEMED VISION NO.
WI475050030Medicare PIN