Provider Demographics
NPI:1881058220
Name:BIANCO, MATTHEW (DPM)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:BIANCO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:784 MEDINA RD STE 107
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-9634
Mailing Address - Country:US
Mailing Address - Phone:330-591-9635
Mailing Address - Fax:330-591-4150
Practice Address - Street 1:784 MEDINA RD STE 107
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-9634
Practice Address - Country:US
Practice Address - Phone:330-591-9635
Practice Address - Fax:330-591-4150
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-12
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
00000000000000000000390200000X
OH36.003897213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty