Healthcare Provider Details

I. General information

NPI: 1003811704
Provider Name (Legal Business Name): ROBERT MUCCIOLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1503 SCALP AVE
JOHNSTOWN PA
15904-3315
US

IV. Provider business mailing address

1086 FRANKLIN ST
JOHNSTOWN PA
15905-4305
US

V. Phone/Fax

Practice location:
  • Phone: 814-262-0333
  • Fax: 814-262-7129
Mailing address:
  • Phone: 814-534-1555
  • Fax: 814-535-8720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD033626E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: