Provider Demographics
NPI:1376500231
Name:MATHEWS, MARK A (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:MATHEWS
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 1:218 S. FRONT ST.
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420
Mailing Address - Country:US
Mailing Address - Phone:419-332-4309
Mailing Address - Fax:419-332-3834
Practice Address - Street 1:218 S. FRONT ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420
Practice Address - Country:US
Practice Address - Phone:419-332-4309
Practice Address - Fax:419-332-3834
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3680T871152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0545020Medicaid
OH410047929OtherMEDICARE RAILROAD
OH0545020Medicaid
OHMA7353801Medicare PIN
OHT96108Medicare UPIN