Provider Demographics
NPI:1043327620
Name:FANUCCHI, MICHAEL PAUL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PAUL
Last Name:FANUCCHI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 BRADHURST AVENUE
Mailing Address - Street 2:SUITE 3100N
Mailing Address - City:HAWTHORNE
Mailing Address - State:NY
Mailing Address - Zip Code:10523-6007
Mailing Address - Country:US
Mailing Address - Phone:914-909-9018
Mailing Address - Fax:
Practice Address - Street 1:19 BRADHURST AVE STE 2300N
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:NY
Practice Address - Zip Code:10532-2140
Practice Address - Country:US
Practice Address - Phone:914-909-9018
Practice Address - Fax:914-493-2416
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY139415207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02913308Medicaid
NYC07218Medicare UPIN
NYA400081937Medicare PIN