Provider Demographics
NPI:1770508632
Name:MATHIESON, BERT WILLIAM (ND,RD,LD,CDE)
Entity Type:Individual
Prefix:DR
First Name:BERT
Middle Name:WILLIAM
Last Name:MATHIESON
Suffix:
Gender:M
Credentials:ND,RD,LD,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 RIVERWAY PL
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03110-6764
Mailing Address - Country:US
Mailing Address - Phone:603-623-6800
Mailing Address - Fax:
Practice Address - Street 1:304 RIVERWAY PL
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:NH
Practice Address - Zip Code:03110-6764
Practice Address - Country:US
Practice Address - Phone:603-623-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH811007133V00000X
NH49175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHMT0793Medicare ID - Type Unspecified