Healthcare Provider Details

I. General information

NPI: 1770553794
Provider Name (Legal Business Name): KEVIN JAMES CUCCINELLI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 02/10/2021
Certification Date: 02/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 E JOHNSON ST
HOLYOKE CO
80734-1854
US

IV. Provider business mailing address

1001 E JOHNSON ST
HOLYOKE CO
80734-1854
US

V. Phone/Fax

Practice location:
  • Phone: 970-854-2241
  • Fax: 970-458-4581
Mailing address:
  • Phone: 970-854-2241
  • Fax: 970-458-4581

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR.0042299
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: