Provider Demographics
NPI:1629037833
Name:MASSIMIANO, PAUL S (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:S
Last Name:MASSIMIANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2921 TELESTAR CT
Mailing Address - Street 2:SUITE 140
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22042-1205
Mailing Address - Country:US
Mailing Address - Phone:703-280-5858
Mailing Address - Fax:703-280-2654
Practice Address - Street 1:2921 TELESTAR CT
Practice Address - Street 2:SUITE 140
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042-1205
Practice Address - Country:US
Practice Address - Phone:703-280-5858
Practice Address - Fax:703-280-2654
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101045274174400000X, 208G00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No174400000XOther Service ProvidersSpecialist
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC031197400Medicaid
KY64073570Medicaid
VA7422113Medicaid
MD350151500Medicaid
KY64073570Medicaid