Provider Demographics
NPI:1033198452
Name:MARTUCCIO, MICHAEL (DC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MARTUCCIO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:369 NILES CORTLAND RD SE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-2430
Mailing Address - Country:US
Mailing Address - Phone:330-856-9595
Mailing Address - Fax:330-856-1411
Practice Address - Street 1:369 NILES CORTLAND RD SE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-2430
Practice Address - Country:US
Practice Address - Phone:330-856-9595
Practice Address - Fax:330-856-1411
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-13
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2254111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0202300Medicaid
OHMA0796754Medicare ID - Type Unspecified
OHU60064Medicare UPIN