Provider Demographics
NPI:1386783066
Name:MATTHEW P. AXLINE, O.D.,LLC
Entity type:Organization
Organization Name:MATTHEW P. AXLINE, O.D.,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:AXLINE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:740-387-8414
Mailing Address - Street 1:399 E CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-4143
Mailing Address - Country:US
Mailing Address - Phone:740-387-8414
Mailing Address - Fax:740-387-9434
Practice Address - Street 1:399 E CHURCH ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-4143
Practice Address - Country:US
Practice Address - Phone:740-387-8414
Practice Address - Fax:740-387-9434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5520152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9350761Medicare ID - Type Unspecified