Provider Demographics
NPI:1437188182
Name:MATHISEN, RONALD ROBIN (OD)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:ROBIN
Last Name:MATHISEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:5549 35TH ST NE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313-3716
Mailing Address - Country:US
Mailing Address - Phone:763-682-9052
Mailing Address - Fax:763-571-3008
Practice Address - Street 1:5549 35TH ST NE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-3716
Practice Address - Country:US
Practice Address - Phone:763-682-9052
Practice Address - Fax:763-782-8100
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2147152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2217160OtherMEDICA #
MNHP19896OtherHEALTHPARTNERS
MN08F74MAOtherBCBS OF MN
MN107309OtherUCARE MN#
MN23667OtherAMERICA'S PPO
MN1000891OtherPREFERRED ONE
MN5439394OtherAETNA INS
MN23667OtherAMERICA'S PPO