Healthcare Provider Details

I. General information

NPI: 1326361163
Provider Name (Legal Business Name): MARION LUCCIOLA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2010
Last Update Date: 03/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 OVERLOOK RD STE 170
SUMMIT NJ
07901-3577
US

IV. Provider business mailing address

129 WALTON AVE
NEW PROVIDENCE NJ
07974-1748
US

V. Phone/Fax

Practice location:
  • Phone: 908-277-4480
  • Fax:
Mailing address:
  • Phone: 908-790-0216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA07901700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: