Healthcare Provider Details

I. General information

NPI: 1346223138
Provider Name (Legal Business Name): MARY PUCCIO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2005
Last Update Date: 12/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 E MAIN ST
BAY SHORE NY
11706-8301
US

IV. Provider business mailing address

24 E MAIN ST
BAY SHORE NY
11706-8301
US

V. Phone/Fax

Practice location:
  • Phone: 631-666-6752
  • Fax: 631-666-0684
Mailing address:
  • Phone: 631-666-6752
  • Fax: 631-666-0684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number193399
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: