Provider Demographics
NPI:1386129252
Name:BIANCONI, GINO J (OD)
Entity type:Individual
Prefix:DR
First Name:GINO
Middle Name:J
Last Name:BIANCONI
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 1:3712 VIRGINIA BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-3414
Mailing Address - Country:US
Mailing Address - Phone:757-463-3576
Mailing Address - Fax:
Practice Address - Street 1:236 CARMICHAEL WAY STE 318
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23322-2185
Practice Address - Country:US
Practice Address - Phone:757-255-1330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-26
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG003485152W00000X
VA0618002712152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist