Healthcare Provider Details

I. General information

NPI: 1003937772
Provider Name (Legal Business Name): KEVIN CUCCARO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 09/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3680 NW SAMARITAN DR
CORVALLIS OR
97330-3737
US

IV. Provider business mailing address

444 NW ELKS DR
CORVALLIS OR
97330-3745
US

V. Phone/Fax

Practice location:
  • Phone: 541-754-1150
  • Fax:
Mailing address:
  • Phone: 541-754-1150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberDO154079
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: