Provider Demographics
NPI:1790047819
Name:MATHIAK, EMILY (OD)
Entity Type:Individual
Prefix:DR
First Name:EMILY
Middle Name:
Last Name:MATHIAK
Suffix:
Gender:F
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 9
Mailing Address - Street 2:
Mailing Address - City:CROW AGENCY
Mailing Address - State:MT
Mailing Address - Zip Code:59022-0009
Mailing Address - Country:US
Mailing Address - Phone:406-638-3465
Mailing Address - Fax:
Practice Address - Street 1:10110 SOUTH 7650 EAST
Practice Address - Street 2:
Practice Address - City:CROW AGENCY
Practice Address - State:MT
Practice Address - Zip Code:59022
Practice Address - Country:US
Practice Address - Phone:406-638-3465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-14
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004704152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist