Healthcare Provider Details

I. General information

NPI: 1891819033
Provider Name (Legal Business Name): JEREMY MICHAEL MATUSZAK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 11/05/2025
Certification Date: 11/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6121 LAKESIDE DR STE 130
RENO NV
89511-8536
US

IV. Provider business mailing address

690 EDISON WAY
RENO NV
89502-4100
US

V. Phone/Fax

Practice location:
  • Phone: 775-225-3304
  • Fax:
Mailing address:
  • Phone: 775-858-3303
  • Fax: 775-284-4595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number12353
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberC144360
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number12353
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: