Healthcare Provider Details

I. General information

NPI: 1750616181
Provider Name (Legal Business Name): LOUIS RANDALL BUCALO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2009
Last Update Date: 10/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 S OCEAN BLVD APT. 7B
POMPANO BEACH FL
33062-2701
US

IV. Provider business mailing address

1430 S OCEAN BLVD APT. 7B
POMPANO BEACH FL
33062-2701
US

V. Phone/Fax

Practice location:
  • Phone: 305-496-7816
  • Fax:
Mailing address:
  • Phone: 305-496-7816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744R1102X
TaxonomyResearch Study Specialist
License Number77004
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: