Provider Demographics
NPI:1336986553
Name:BLANGO, MATTHEW
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:BLANGO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10718 TAYLOR FARM RD
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:MD
Mailing Address - Zip Code:21163-1429
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10718 TAYLOR FARM RD
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:MD
Practice Address - Zip Code:21163-1429
Practice Address - Country:US
Practice Address - Phone:410-868-4401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-15
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program