Provider Demographics
NPI:1275560435
Name:MATHEWS, MARK W
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:MATHEWS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8319 EMBASSY BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34668
Mailing Address - Country:US
Mailing Address - Phone:727-819-0440
Mailing Address - Fax:727-819-9795
Practice Address - Street 1:8319 EMBASSY BLVD
Practice Address - Street 2:
Practice Address - City:PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34668
Practice Address - Country:US
Practice Address - Phone:727-819-0440
Practice Address - Fax:727-819-9795
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1388152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDN0867OtherRAILROAD GROUP PTAN
0763230001OtherPALMETTO
19872OtherINDIVIDUAL BCBS
33801OtherGROUP BCBS
232279OtherAMERIGROUP
FL084932400Medicaid
FL410022395OtherRAILROAD GROUP MEMBER PTAN
FL1518098102OtherRAILROAD GROUP NPI
410022395OtherRAILROAD MEDICARE
FL1275560435OtherMEDICARE NPI
FL1275560435OtherRAILROAD INDIVIDUAL NPI
110527OtherECPA-EYE MED
0763230001OtherPALMETTO
FL1275560435OtherRAILROAD INDIVIDUAL NPI
33801Medicare PIN