MEDICARE: MR. PAUL BUCOLO MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	3476	FL
2	207Q00000X	Family Medicine Physician	PA3476	FL
3	207Q00000X	Family Medicine Physician	ME143433	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1871633719
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PAUL BUCOLO MD

Provider Business Mailing Address
First Line	:	250 HARRISON ST
Second Line	:
City	:	TITUSVILLE
State	:	FL
Zip	:	32780-5094
Country	:	US
Telephone Number	:	321-268-6868
Fax Number	:	321-267-2713

Provider Business Practice Location Address
First Line	:	125 FLORIDA MEMORIAL PKWY STE 2200
Second Line	:
City	:	NEW SMYRNA BEACH
State	:	FL
Zip	:	32168-9309
Country	:	US
Telephone Number	:	386-409-6839
Fax Number	:	386-409-6916

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/08/2007
Last Update Date	:	04/10/2023

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Directions to “ MR. PAUL BUCOLO MD” Practice Location

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