Provider Demographics
NPI:1164413019
Name:BUCCILLI, THEODORE A JR (DPM)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:A
Last Name:BUCCILLI
Suffix:JR
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 S MAIN ST
Mailing Address - Street 2:STE 7
Mailing Address - City:MUNROE FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44262-1660
Mailing Address - Country:US
Mailing Address - Phone:234-706-2395
Mailing Address - Fax:234-678-8222
Practice Address - Street 1:4403 CLOVER DR
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-8636
Practice Address - Country:US
Practice Address - Phone:330-687-7464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003352213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2538178Medicaid
OH2538178Medicaid
OHV04013Medicare UPIN