Basic Information
| Provider Information | |||||||||
| NPI: | 1881685667 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATHIE | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1403 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446412310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308754320 | ||||||||
| FaxNumber: | 3308754305 | ||||||||
| Practice Location | |||||||||
| Address1: | 4865 FRANK AVE NW | ||||||||
| Address2: | |||||||||
| City: | NORTH CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447207425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304941710 | ||||||||
| FaxNumber: | 3304945815 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2005 | ||||||||
| LastUpdateDate: | 12/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4803 | OH | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 000000223574 | 01 | OH | ANTHEM BLUE CROSS BLUE SH | OTHER | 2039127 | 05 | OH | MEDICAID | OH4803 | 01 | OH | EYEMED | OTHER | 2708610 | 01 | OH | AETNA | OTHER |