Provider Demographics
NPI:1649798620
Name:CIANCA, MICHAEL (OD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:CIANCA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 DIMOCK STREET-DIMCOK COMMUNITY HEALTH CENTER
Mailing Address - Street 2:
Mailing Address - City:ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02119
Mailing Address - Country:US
Mailing Address - Phone:617-442-8800
Mailing Address - Fax:
Practice Address - Street 1:63 MAIN ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301
Practice Address - Country:US
Practice Address - Phone:508-559-6699
Practice Address - Fax:508-559-5073
Is Sole Proprietor?:No
Enumeration Date:2017-08-30
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5230152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist