Provider Demographics
NPI:1477605962
Name:GERARD A COLUCCELLI MD PA
Entity Type:Organization
Organization Name:GERARD A COLUCCELLI MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GERARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:COLUCCELLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-346-3506
Mailing Address - Street 1:1235 SAN MARCO BLVD
Mailing Address - Street 2:401
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207
Mailing Address - Country:US
Mailing Address - Phone:904-346-3506
Mailing Address - Fax:904-346-0712
Practice Address - Street 1:1235 SAN MARCO BLVD
Practice Address - Street 2:401
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207
Practice Address - Country:US
Practice Address - Phone:904-346-3506
Practice Address - Fax:904-346-0712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME39542207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK2484OtherMEDICARE
FL15671OtherBLUE CROSS BLUE SHIELD
FLCH6993Medicare PIN
FLK2484OtherMEDICARE
FL15671OtherBLUE CROSS BLUE SHIELD