Provider Demographics
NPI:1548564941
Name:IANNUCCILLO, ANTHONY (OD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:
Last Name:IANNUCCILLO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 WOOD DALE DR.
Mailing Address - Street 2:
Mailing Address - City:BALLSTON LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12019
Mailing Address - Country:US
Mailing Address - Phone:518-877-7373
Mailing Address - Fax:
Practice Address - Street 1:5 WOOD DALE DR.
Practice Address - Street 2:
Practice Address - City:BALLSTON LAKE
Practice Address - State:NY
Practice Address - Zip Code:12019
Practice Address - Country:US
Practice Address - Phone:518-877-7373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-29
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYT003085152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist