MEDICARE: DR. LAURA ANN BUCCELLATO OD

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	152W00000X	Optometrist	TUV6227-1	NY

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
5	CDWGG1	OTHER	NY	PTAN MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7002866	OTHER	NY	CIGNA
2	C407A1	OTHER	NY	EMPIRE
3	P3585214	OTHER	NY	OXFORD
4	6599232	OTHER	NY	GHI
6	2529608	OTHER	NY	UNITED HEALTHCARE

General Provider Information

NPI Number	:	1932182938
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAURA ANN BUCCELLATO OD

Provider Business Mailing Address
First Line	:	388 HAWKINS AVE
Second Line	:	SUITE 2
City	:	RONKONKOMA
State	:	NY
Zip	:	11779-4280
Country	:	US
Telephone Number	:	631-588-7004
Fax Number	:	631-588-2612

Provider Business Practice Location Address
First Line	:	388 HAWKINS AVE
Second Line	:	SUITE 2
City	:	RONKONKOMA
State	:	NY
Zip	:	11779-4280
Country	:	US
Telephone Number	:	631-588-7004
Fax Number	:	631-588-2612

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

Provider Enumeration Date	:	11/22/2005
Last Update Date	:	05/12/2021

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