Healthcare Provider Details

I. General information

NPI: 1932182938
Provider Name (Legal Business Name): LAURA ANN BUCCELLATO OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURA ANN GILLESPIE OD

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 05/12/2021
Certification Date: 05/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

388 HAWKINS AVE SUITE 2
RONKONKOMA NY
11779-4280
US

IV. Provider business mailing address

388 HAWKINS AVE SUITE 2
RONKONKOMA NY
11779-4280
US

V. Phone/Fax

Practice location:
  • Phone: 631-588-7004
  • Fax: 631-588-2612
Mailing address:
  • Phone: 631-588-7004
  • Fax: 631-588-2612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV6227-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: