Provider Demographics
NPI:1013953116
Name:MATHIE, BRIAN M (OD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:M
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 1:5890 MAYFAIR RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-1547
Mailing Address - Country:US
Mailing Address - Phone:330-305-2200
Mailing Address - Fax:330-305-2210
Practice Address - Street 1:5890 MAYFAIR RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-1547
Practice Address - Country:US
Practice Address - Phone:330-305-2200
Practice Address - Fax:330-305-2210
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4213152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
001301628OtherKEYSTONE HEALTH/HIGHMARK
000000203490OtherANTHEM
OH0844779Medicaid
1404675OtherUNITED HEALTH CARE
OH4384872OtherAETNA
OH4384872OtherAETNA
OH0683357Medicare ID - Type Unspecified
410045703Medicare ID - Type UnspecifiedRAILROAD MEDICARE