Provider Demographics
NPI:1023288610
Name:KEVIN R MATHISSON MD PC
Entity type:Organization
Organization Name:KEVIN R MATHISSON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:MATHISSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:914-723-2020
Mailing Address - Street 1:455 CENTRAL PARK AVE STE 317
Mailing Address - Street 2:
Mailing Address - City:SCARSDALE
Mailing Address - State:NY
Mailing Address - Zip Code:10583-1060
Mailing Address - Country:US
Mailing Address - Phone:914-337-2222
Mailing Address - Fax:914-723-2011
Practice Address - Street 1:455 CENTRAL PARK AVE STE 317
Practice Address - Street 2:
Practice Address - City:SCARSDALE
Practice Address - State:NY
Practice Address - Zip Code:10583-1060
Practice Address - Country:US
Practice Address - Phone:914-723-2020
Practice Address - Fax:914-723-2011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-10
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY198609207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWTW011Medicare PIN