Provider Demographics
NPI:1144315821
Name:MATHIESON, MARK EUGENE (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:EUGENE
Last Name:MATHIESON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:258 TREEMONTE DR
Mailing Address - Street 2:STE 258
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-7945
Mailing Address - Country:US
Mailing Address - Phone:386-628-3376
Mailing Address - Fax:386-877-0188
Practice Address - Street 1:258 TREEMONTE DR
Practice Address - Street 2:STE 258
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-7945
Practice Address - Country:US
Practice Address - Phone:386-628-3376
Practice Address - Fax:386-877-0188
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME128227208200000X, 2086S0122X, 207N00000X
OH35077172M208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2331631Medicaid
FLME1281227OtherMEDICAL LICENSE
OH2331631Medicaid