Basic Information
| Provider Information | |||||||||
| NPI: | 1437188182 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATHISEN | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | ROBIN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5549 35TH ST NE | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553133716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7636829052 | ||||||||
| FaxNumber: | 7635713008 | ||||||||
| Practice Location | |||||||||
| Address1: | 5549 35TH ST NE | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553133716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7636829052 | ||||||||
| FaxNumber: | 7637828100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2147 | MN | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 2217160 | 01 | MN | MEDICA # | OTHER | HP19896 | 01 | MN | HEALTHPARTNERS | OTHER | 08F74MA | 01 | MN | BCBS OF MN | OTHER | 107309 | 01 | MN | UCARE MN# | OTHER | 23667 | 01 | MN | AMERICA'S PPO | OTHER | 1000891 | 01 | MN | PREFERRED ONE | OTHER | 5439394 | 01 | MN | AETNA INS | OTHER |