Provider Demographics
NPI:1265434948
Name:BANCO, ROBERT J (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:BANCO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:25 WASHINGTON ST UNIT 1B
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY HILLS
Mailing Address - State:MA
Mailing Address - Zip Code:02481-1752
Mailing Address - Country:US
Mailing Address - Phone:617-219-6300
Mailing Address - Fax:617-219-6355
Practice Address - Street 1:25 WASHINGTON ST UNIT 1B
Practice Address - Street 2:
Practice Address - City:WELLESLEY HILLS
Practice Address - State:MA
Practice Address - Zip Code:02481-1752
Practice Address - Country:US
Practice Address - Phone:617-219-6300
Practice Address - Fax:617-219-6355
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA59668207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3043053Medicaid
MAJ07331Medicare ID - Type Unspecified
MA3043053Medicaid