Provider Demographics
NPI:1922093210
Name:MATRISCIANO, JUSTIN GRADY (MD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:GRADY
Last Name:MATRISCIANO
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 1:535 FAUNCE CORNER RD
Mailing Address - Street 2:
Mailing Address - City:DARTMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02747-1242
Mailing Address - Country:US
Mailing Address - Phone:508-996-3991
Mailing Address - Fax:
Practice Address - Street 1:535 FAUNCE CORNER RD
Practice Address - Street 2:
Practice Address - City:DARTMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02747-1242
Practice Address - Country:US
Practice Address - Phone:508-996-3991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA202783207RE0101X
MA159233207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1886386Medicaid
LA5F809Medicare PIN
LA4M020F809Medicare PIN