Healthcare Provider Details

I. General information

NPI: 1366480071
Provider Name (Legal Business Name): EDWARD F. NUCCIO O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 09/06/2023
Certification Date: 09/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 E ORANGEBURG AVE STE 208
MODESTO CA
95355-3395
US

IV. Provider business mailing address

2401 E ORANGEBURG AVE STE 208
MODESTO CA
95355-3395
US

V. Phone/Fax

Practice location:
  • Phone: 209-525-8436
  • Fax:
Mailing address:
  • Phone: 209-525-8436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number8000TPLG
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: