Provider Demographics
NPI:1477635688
Name:CUCURULLO, ROBERTO EDMUNDO (PA)
Entity Type:Individual
Prefix:MR
First Name:ROBERTO
Middle Name:EDMUNDO
Last Name:CUCURULLO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7761 NW 146TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33016-1559
Mailing Address - Country:US
Mailing Address - Phone:305-822-5896
Mailing Address - Fax:305-822-4260
Practice Address - Street 1:7761 NW 146TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33016-1559
Practice Address - Country:US
Practice Address - Phone:305-822-5896
Practice Address - Fax:305-822-4260
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9100128363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290459400Medicaid
FL292745OtherAV-MED