Provider Demographics
NPI:1568874907
Name:MERGENTHALER, MATHEW BRYAN (OD)
Entity Type:Individual
Prefix:DR
First Name:MATHEW
Middle Name:BRYAN
Last Name:MERGENTHALER
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:PO BOX 547
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:WI
Mailing Address - Zip Code:54451-0547
Mailing Address - Country:US
Mailing Address - Phone:715-748-2020
Mailing Address - Fax:715-748-4565
Practice Address - Street 1:309 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:WI
Practice Address - Zip Code:54451-1835
Practice Address - Country:US
Practice Address - Phone:715-748-2020
Practice Address - Fax:715-748-2020
Is Sole Proprietor?:No
Enumeration Date:2014-05-20
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA073539152W00000X
WI3359152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100039841Medicaid
WIK400161285Medicare UPIN