Provider Demographics
NPI:1477646172
Name:BUCALO, BRIAN (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:BUCALO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10067 PINES BLVD.
Mailing Address - Street 2:SUITE A
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024
Mailing Address - Country:US
Mailing Address - Phone:954-436-5625
Mailing Address - Fax:954-436-0115
Practice Address - Street 1:10067 PINES BLVD.
Practice Address - Street 2:SUITE A
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024
Practice Address - Country:US
Practice Address - Phone:954-436-5625
Practice Address - Fax:954-436-0115
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBB1760164174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF16050Medicare UPIN