Provider Demographics
NPI:1063505345
Name:MARTUCCIO, GEORGE (OD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:
Last Name:MARTUCCIO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 NAVAJO TRL
Mailing Address - Street 2:
Mailing Address - City:GIRARD
Mailing Address - State:OH
Mailing Address - Zip Code:44420-3633
Mailing Address - Country:US
Mailing Address - Phone:724-346-5950
Mailing Address - Fax:724-342-6246
Practice Address - Street 1:1275 N HERMITAGE RD
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:PA
Practice Address - Zip Code:16148-3110
Practice Address - Country:US
Practice Address - Phone:724-346-5950
Practice Address - Fax:724-342-6246
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001327152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAU12574Medicare UPIN
MA693902Medicare ID - Type Unspecified