Provider Demographics
NPI:1063548790
Name:TREGO, MATTHEW (OD)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:TREGO
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 1:3530 WEIKERT RD
Mailing Address - Street 2:
Mailing Address - City:MILLMONT
Mailing Address - State:PA
Mailing Address - Zip Code:17845-9311
Mailing Address - Country:US
Mailing Address - Phone:570-323-8000
Mailing Address - Fax:570-326-2880
Practice Address - Street 1:567 E 3RD ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-5316
Practice Address - Country:US
Practice Address - Phone:570-323-8000
Practice Address - Fax:570-326-2880
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG-001458152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAOEG-001458OtherSTATE LICENSE
PWV00671Medicare UPIN