Provider Demographics
NPI:1063511483
Name:CAPPARUCCINI, MARIO (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:
Last Name:CAPPARUCCINI
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 1:1020 VESTAL PKWY E
Mailing Address - Street 2:
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850-1748
Mailing Address - Country:US
Mailing Address - Phone:607-754-5342
Mailing Address - Fax:607-754-5508
Practice Address - Street 1:1020 VESTAL PKWY E
Practice Address - Street 2:
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-1748
Practice Address - Country:US
Practice Address - Phone:607-754-5342
Practice Address - Fax:607-754-5508
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY221619207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02163413Medicaid
NYD01189Medicare UPIN
NY02163413Medicaid