Provider Demographics
NPI:1275507733
Name:PUCCIO, JEFFREY EUGENE (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:EUGENE
Last Name:PUCCIO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47830 BECKENHAM BLVD
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48374-3530
Mailing Address - Country:US
Mailing Address - Phone:248-347-7808
Mailing Address - Fax:248-347-7823
Practice Address - Street 1:2021 MONROE ST
Practice Address - Street 2:SUITE 101
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2926
Practice Address - Country:US
Practice Address - Phone:313-277-4177
Practice Address - Fax:313-277-2157
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301052835174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIF60066Medicare UPIN