Provider Demographics
NPI:1275618597
Name:MATEOSSIAN, ROGER (OD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:
Last Name:MATEOSSIAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1261 BARING BLVD
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89434-8673
Mailing Address - Country:US
Mailing Address - Phone:775-353-5665
Mailing Address - Fax:775-353-5660
Practice Address - Street 1:3915 BAKER LANE
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-5544
Practice Address - Country:US
Practice Address - Phone:775-825-3232
Practice Address - Fax:775-689-2494
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV126152W00000X
CACA5302152W00000X
ID489152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00244142OtherRAILROAD MEDICARE
T67296Medicare UPIN
100806Medicare PIN