Provider Demographics
NPI:1811003957
Name:AXLINE, MATTHEW PAUL (OD OPTOMETRIST)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:PAUL
Last Name:AXLINE
Suffix:
Gender:M
Credentials:OD OPTOMETRIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:399 E CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-4143
Mailing Address - Country:US
Mailing Address - Phone:740-387-8414
Mailing Address - Fax:740-382-9434
Practice Address - Street 1:905 S POPLAR ST
Practice Address - Street 2:
Practice Address - City:BUCYRUS
Practice Address - State:OH
Practice Address - Zip Code:44820-2663
Practice Address - Country:US
Practice Address - Phone:419-562-3822
Practice Address - Fax:419-562-9939
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5520152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2522121Medicaid
OH41513519350761Medicare ID - Type UnspecifiedGROUP
OH2522121Medicaid