Healthcare Provider Details

I. General information

NPI: 1437188182
Provider Name (Legal Business Name): RONALD ROBIN MATHISEN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5549 35TH ST NE
BUFFALO MN
55313-3716
US

IV. Provider business mailing address

5549 35TH ST NE
BUFFALO MN
55313-3716
US

V. Phone/Fax

Practice location:
  • Phone: 763-682-9052
  • Fax: 763-782-8100
Mailing address:
  • Phone: 763-682-9052
  • Fax: 763-571-3008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2147
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: