Provider Demographics
NPI:1992062012
Name:BRANIECKI, MATTHEW A (DO)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:A
Last Name:BRANIECKI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1031 PIERCE ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-4669
Mailing Address - Country:US
Mailing Address - Phone:419-557-5568
Mailing Address - Fax:419-557-5542
Practice Address - Street 1:3960 E HARBOR RD
Practice Address - Street 2:
Practice Address - City:PORT CLINTON
Practice Address - State:OH
Practice Address - Zip Code:43452-2670
Practice Address - Country:US
Practice Address - Phone:419-732-0700
Practice Address - Fax:419-732-0702
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-13
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH34011656207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0121443Medicaid