Provider Demographics
NPI:1679705198
Name:PISANO, MATTHEW (RD)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:PISANO
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 DROVER RD
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06804-3507
Mailing Address - Country:US
Mailing Address - Phone:203-313-1803
Mailing Address - Fax:
Practice Address - Street 1:2475 SAINT RAYMONDS AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-3124
Practice Address - Country:US
Practice Address - Phone:718-430-4386
Practice Address - Fax:718-822-0592
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-17
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT10128554133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered