Healthcare Provider Details

I. General information

NPI: 1669429130
Provider Name (Legal Business Name): GREGORY CUCULINO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: GREGORY P CUCULINO MD

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 01/22/2025
Certification Date: 01/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 S PENINSULA DR
DAYTONA BEACH FL
32118-4422
US

IV. Provider business mailing address

222 S PENINSULA DR
DAYTONA BEACH FL
32118-4422
US

V. Phone/Fax

Practice location:
  • Phone: 386-310-2160
  • Fax: 386-310-2106
Mailing address:
  • Phone: 386-310-2160
  • Fax: 386-310-2106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD067278L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberME131250
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: