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General NPI Number Information
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NPI Number | 1013957059
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Entity Type | Individual
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Provider Name | KENNETH F MATTUCCI M.D.
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Gender | Male
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Dates
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Enumeration Date | 06/07/2006
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Last Update Date | 11/25/2008
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Provider Practice Location Address
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Address Line | 29 BARSTOW RD SUITE 203
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City | GREAT NECK
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State | NY
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Zip | 11021-2209
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Country | US
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Telephone | 516-482-7960
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Fax | 516-482-4122
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Provider Business Mailing Address
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Address Line | 11 NOME DR
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City | WOODBURY
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State | NY
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Zip | 11797-3404
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Country | US
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Telephone | 516-367-4281
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Fax | 516-367-3134
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 096685
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License Number State | NY
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