Provider Demographics
NPI:1942048285
Name:MATEO, EDGARDO BLANCO II
Entity type:Individual
Prefix:
First Name:EDGARDO
Middle Name:BLANCO
Last Name:MATEO
Suffix:II
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 1:447 PLUMTREE RD BSMT
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01118-1627
Mailing Address - Country:US
Mailing Address - Phone:413-316-3308
Mailing Address - Fax:
Practice Address - Street 1:447 PLUMTREE RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01118-1627
Practice Address - Country:US
Practice Address - Phone:413-316-3308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-19
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12461225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist