Healthcare Provider Details

I. General information

NPI: 1396702486
Provider Name (Legal Business Name): MARINA A MAULUCCI D.P.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 03/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 ELLICOTT CREEK RD STE 1
TONAWANDA NY
14150-2935
US

IV. Provider business mailing address

1540 ELLICOTT CREEK RD STE 1
TONAWANDA NY
14150-2935
US

V. Phone/Fax

Practice location:
  • Phone: 716-886-8289
  • Fax: 716-886-8303
Mailing address:
  • Phone: 716-886-8289
  • Fax: 716-886-8303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberN003952
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberN003952
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code213ER0200X
TaxonomyRadiology Podiatrist
License NumberN003952
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License NumberN003952
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberN003952
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: