Provider Demographics
NPI:1326063264
Name:FIANDACA, MASSIMO S (MD)
Entity Type:Individual
Prefix:DR
First Name:MASSIMO
Middle Name:S
Last Name:FIANDACA
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 1:402 WILDBERRY CT
Mailing Address - Street 2:
Mailing Address - City:MILLERSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21108-1888
Mailing Address - Country:US
Mailing Address - Phone:410-772-3685
Mailing Address - Fax:410-772-3686
Practice Address - Street 1:11055 LITTLE PATUXENT PKWY
Practice Address - Street 2:SUITE 209
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-2896
Practice Address - Country:US
Practice Address - Phone:410-772-3685
Practice Address - Fax:410-772-3686
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD41956174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDA66628Medicare UPIN
MD177P415GMedicare ID - Type Unspecified