Provider Demographics
NPI:1073670303
Name:MUCCIARDI, NICK (MD)
Entity Type:Individual
Prefix:DR
First Name:NICK
Middle Name:
Last Name:MUCCIARDI
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 1:200 MILL RD
Mailing Address - Street 2:SUITE 180
Mailing Address - City:FAIRHAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02719-5252
Mailing Address - Country:US
Mailing Address - Phone:508-973-2000
Mailing Address - Fax:508-973-2001
Practice Address - Street 1:1030 PRESIDENT AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-5923
Practice Address - Country:US
Practice Address - Phone:508-973-1780
Practice Address - Fax:508-973-0359
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD06886207RP1001X
MA44581207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
RINM04777Medicaid
MA110064580AMedicaid
MA110064580AMedicaid
RINM04777Medicaid
MA6177948Medicaid
RI007056478Medicare ID - Type Unspecified
MAJ03191Medicare ID - Type Unspecified
RI203039OtherBLUECHIP OF RI
RI293820OtherBLUE CROSS BLUE SHIELD
RI30342OtherNEIGHBORHOOD HEALTH PLAN
MAJ03191OtherBLUE CROSS BLUE SHIELD
GA110046943OtherRAILROAD MEDICARE
MA006886OtherTUFTS
MA6493OtherHARVARD PILGRIM HEALTH