Healthcare Provider Details

I. General information

NPI: 1013953116
Provider Name (Legal Business Name): BRIAN M MATHIE O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5890 MAYFAIR RD
CANTON OH
44720-1547
US

IV. Provider business mailing address

5890 MAYFAIR RD
CANTON OH
44720-1547
US

V. Phone/Fax

Practice location:
  • Phone: 330-305-2200
  • Fax: 330-305-2210
Mailing address:
  • Phone: 330-305-2200
  • Fax: 330-305-2210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4213
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: