Provider Demographics
NPI:1629110028
Name:MEZZANO, ROSANNE (OD)
Entity type:Individual
Prefix:DR
First Name:ROSANNE
Middle Name:
Last Name:MEZZANO
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 1:6407 N ILLINOIS ST
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:62208
Mailing Address - Country:US
Mailing Address - Phone:618-398-5005
Mailing Address - Fax:618-852-1930
Practice Address - Street 1:6407 N ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208
Practice Address - Country:US
Practice Address - Phone:618-398-5005
Practice Address - Fax:618-852-1930
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046 008911152W00000X
IL0460088911152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU63126Medicare UPIN