Healthcare Provider Details

I. General information

NPI: 1942237441
Provider Name (Legal Business Name): MARK W TUCCILLO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 FRAM STREET
PETERSBURG AK
99833-0589
US

IV. Provider business mailing address

PO BOX 2120
PETERSBURG AK
99833-2120
US

V. Phone/Fax

Practice location:
  • Phone: 907-772-4299
  • Fax:
Mailing address:
  • Phone: 907-772-3975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberAA2935
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: