Healthcare Provider Details

I. General information

NPI: 1629554738
Provider Name (Legal Business Name): MATTHEW JOSEPH BANKOWSKI MS, PHD, D(ABMM)
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2018
Last Update Date: 12/23/2023
Certification Date: 12/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7608 HAMPTON HILLS LOOP
NEW PORT RICHEY FL
34654-6207
US

IV. Provider business mailing address

7608 HAMPTON HILLS LOOP
NEW PORT RICHEY FL
34654-6207
US

V. Phone/Fax

Practice location:
  • Phone: 612-801-2597
  • Fax:
Mailing address:
  • Phone: 612-801-2597
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License NumberDI30550
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207ZM0300X
TaxonomyMedical Microbiology Physician
License NumberDI30550
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: