Provider Demographics
NPI:1063831618
Name:BELLANCO, NICHOLAS R (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:R
Last Name:BELLANCO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6438 WILMINGTON PIKE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-7022
Mailing Address - Country:US
Mailing Address - Phone:937-558-3840
Mailing Address - Fax:937-558-3844
Practice Address - Street 1:6438 WILMINGTON PIKE
Practice Address - Street 2:SUITE 100
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-7022
Practice Address - Country:US
Practice Address - Phone:937-558-3840
Practice Address - Fax:937-558-3844
Is Sole Proprietor?:No
Enumeration Date:2014-04-10
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X
OH35128647207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0119933Medicaid
OH0213990Medicaid
OH0213990Medicaid