Provider Demographics
NPI:1356377618
Name:VISO, MATTHEW JOSEPH (DC)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JOSEPH
Last Name:VISO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 GREENMIST DR
Mailing Address - Street 2:
Mailing Address - City:LAKE RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-4559
Mailing Address - Country:US
Mailing Address - Phone:631-676-6665
Mailing Address - Fax:
Practice Address - Street 1:55 2ND AVE
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-4665
Practice Address - Country:US
Practice Address - Phone:631-617-5733
Practice Address - Fax:631-617-5731
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009235111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU73680Medicare UPIN