Healthcare Provider Details

I. General information

NPI: 1760002810
Provider Name (Legal Business Name): BENJAMIN JOHN PUCCIO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2020
Last Update Date: 07/25/2025
Certification Date: 07/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 SAINT ANTOINE ST STE 8A&8B
DETROIT MI
48201-2153
US

IV. Provider business mailing address

400 MACK AVE
DETROIT MI
48201-2136
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-4275
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number4301515133
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: