Provider Demographics
NPI:1609123660
Name:MATSKO, STEPHANIE RENE (OD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:RENE
Last Name:MATSKO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4114 INNSLAKE DR.
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060
Mailing Address - Country:US
Mailing Address - Phone:804-217-9883
Mailing Address - Fax:804-217-9065
Practice Address - Street 1:4114 INNSLAKE DR.
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060
Practice Address - Country:US
Practice Address - Phone:804-217-9883
Practice Address - Fax:804-217-9065
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-09
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1703152W00000X
VA0618002176152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist