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General NPI Number Information
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NPI Number | 1134236847
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Entity Type | Organization
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Legal Business Name | GERARD A.COLUCCELLI,M.D.
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Dates
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Enumeration Date | 08/25/2006
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Last Update Date | 11/14/2007
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Provider Practice Location Address
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Address Line | 1235 SAN MARCO BLVD SUITE 401
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City | JACKSONVILLE
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State | FL
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Zip | 32207-8554
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Country | US
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Telephone | 904-398-2111
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Fax | 904-346-0712
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Provider Business Mailing Address
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Address Line | 1235 SAN MARCO BLVD SUITE 401
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City | JACKSONVILLE
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State | FL
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Zip | 32207-8554
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Country | US
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Telephone | 904-398-2111
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Fax | 904-346-0712
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Authorized Official
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Title or Position | OWNER
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Name | GERARD A COLUCCELLI
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Credential | M.D.
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Telephone | 904-398-2111
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | ME39542
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License Number State | FL
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