Healthcare Provider Details

I. General information

NPI: 1255326997
Provider Name (Legal Business Name): MICHAEL A BELLUCCI OPTOMETRIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 10/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1524 ATWOOD AVE
JOHNSTON RI
02919-3228
US

IV. Provider business mailing address

1524 ATWOOD AVE
JOHNSTON RI
02919-3228
US

V. Phone/Fax

Practice location:
  • Phone: 401-272-2110
  • Fax: 401-273-6236
Mailing address:
  • Phone: 401-272-2110
  • Fax: 401-272-0388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODTG00457
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: