Provider Demographics
NPI:1629029418
Name:MATTELIANO, ANDREW CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:CHARLES
Last Name:MATTELIANO
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 1:235 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14201-1401
Mailing Address - Country:US
Mailing Address - Phone:716-882-0726
Mailing Address - Fax:716-882-3484
Practice Address - Street 1:235 NORTH ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14201-1401
Practice Address - Country:US
Practice Address - Phone:716-882-0726
Practice Address - Fax:716-882-3484
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1598681174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
005044311OtherBLUE CROSS OF WNY
NY00959297Medicaid
00020527401OtherUNIVERA
000504431001OtherCOMMUNITY BLUE
00640512OtherGHI
3006860OtherINDEPENDENT HEALTH
NY00959297Medicaid