Provider Demographics
NPI:1881685667
Name:MATHIE, BRUCE P (OD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:P
Last Name:MATHIE
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 1:1403 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44641-2310
Mailing Address - Country:US
Mailing Address - Phone:330-875-4320
Mailing Address - Fax:330-875-4305
Practice Address - Street 1:4865 FRANK AVE NW
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-7425
Practice Address - Country:US
Practice Address - Phone:330-494-1710
Practice Address - Fax:330-494-5815
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4803152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000223574OtherANTHEM BLUE CROSS BLUE SH
OH2039127Medicaid
OHOH4803OtherEYEMED
OH2708610OtherAETNA
OHU43517Medicare UPIN
OH0855075Medicare PIN
OH410048659Medicare PIN
OH4441030001Medicare NSC