Provider Demographics
NPI:1487659256
Name:MATHIS, MALISSA T (OD)
Entity Type:Individual
Prefix:DR
First Name:MALISSA
Middle Name:T
Last Name:MATHIS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:180 N DEAN ST
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29302-1517
Mailing Address - Country:US
Mailing Address - Phone:864-583-3125
Mailing Address - Fax:864-542-1367
Practice Address - Street 1:1506 N LIMESTONE ST
Practice Address - Street 2:
Practice Address - City:GAFFNEY
Practice Address - State:SC
Practice Address - Zip Code:29340-4747
Practice Address - Country:US
Practice Address - Phone:864-489-2016
Practice Address - Fax:864-488-1123
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1092152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U68373Medicare UPIN