Provider Demographics
NPI:1912492919
Name:MATTISON, VAN MAI (OD)
Entity Type:Individual
Prefix:
First Name:VAN
Middle Name:MAI
Last Name:MATTISON
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 1:2880 DAVID WALKER DR # 260
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-6172
Mailing Address - Country:US
Mailing Address - Phone:321-754-0581
Mailing Address - Fax:
Practice Address - Street 1:112 E DIXIE AVE
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-6350
Practice Address - Country:US
Practice Address - Phone:352-787-1956
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-22
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC5557152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist