Provider Demographics
NPI:1396968913
Name:MATTIX, GARY BUHRMESTER (LDO)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:BUHRMESTER
Last Name:MATTIX
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 SLEATER KINNEY RD SE
Mailing Address - Street 2:SUITE E
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-1113
Mailing Address - Country:US
Mailing Address - Phone:360-438-9458
Mailing Address - Fax:360-438-8902
Practice Address - Street 1:700 SLEATER KINNEY RD SE
Practice Address - Street 2:SUITE E
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1113
Practice Address - Country:US
Practice Address - Phone:360-438-9458
Practice Address - Fax:360-438-8902
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA398156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2009124Medicaid
WA2009124Medicaid