Provider Demographics
NPI:1093883845
Name:PUCCIO, VINCENT JAMES (DPT)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:JAMES
Last Name:PUCCIO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1545 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-3503
Mailing Address - Country:US
Mailing Address - Phone:718-720-2288
Mailing Address - Fax:718-720-5444
Practice Address - Street 1:1545 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3503
Practice Address - Country:US
Practice Address - Phone:718-720-2288
Practice Address - Fax:718-720-5444
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015682225100000X
NJ06504225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY191680POtherHIP PRIS #
NYP2818653OtherOXFORD OUT OF NETWORK
NY6698497OtherGHI
NY191680POtherHIP PRIS #