Provider Demographics
NPI:1730319021
Name:MATHISEN OPTOMETRY,LLC
Entity Type:Organization
Organization Name:MATHISEN OPTOMETRY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:ROBIN
Authorized Official - Last Name:MATHISEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-229-2235
Mailing Address - Street 1:5549 35TH ST NE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313-3716
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5549 35TH ST NE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-3716
Practice Address - Country:US
Practice Address - Phone:873-229-2235
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-21
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY223T152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Single Specialty