Provider Demographics
NPI:1982155701
Name:MATHERNE, MICHAEL (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MATHERNE
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 1:6765 LANKERSHIM BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-1614
Mailing Address - Country:US
Mailing Address - Phone:818-982-0076
Mailing Address - Fax:818-982-0634
Practice Address - Street 1:6765 LANKERSHIM BLVD
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606
Practice Address - Country:US
Practice Address - Phone:818-982-0076
Practice Address - Fax:818-982-0634
Is Sole Proprietor?:No
Enumeration Date:2016-10-17
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1839-773AT152W00000X
CAOPT33865TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT33865TLGOtherBOARD OF OPTOMETRY