Healthcare Provider Details

I. General information

NPI: 1306845540
Provider Name (Legal Business Name): EDWARD A PUCCI D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 11/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 N MAPLE AVE SUITE 205
RIDGEWOOD NJ
07450-3255
US

IV. Provider business mailing address

61 N MAPLE AVE SUITE 205
RIDGEWOOD NJ
07450-3255
US

V. Phone/Fax

Practice location:
  • Phone: 201-447-2808
  • Fax: 201-447-2809
Mailing address:
  • Phone: 201-447-2808
  • Fax: 201-447-2809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number231342
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: