Provider Demographics
NPI:1366497661
Name:MATTIA, ROVETTA MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:ROVETTA
Middle Name:MARIE
Last Name:MATTIA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:7230 ORCHARD LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3603
Mailing Address - Country:US
Mailing Address - Phone:248-661-5100
Mailing Address - Fax:215-661-8816
Practice Address - Street 1:735 JOHN R RD STE 150
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-5859
Practice Address - Country:US
Practice Address - Phone:248-577-3659
Practice Address - Fax:248-588-9917
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTPOP149152W00000X
AZOPT-002655152W00000X
MIRQ004081152W00000X
MI4901004081152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU83987Medicare UPIN