Provider Demographics
NPI:1578030458
Name:RAUCCI, KIMBERLY (OD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:RAUCCI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 CORONA DR
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-3514
Mailing Address - Country:US
Mailing Address - Phone:203-606-6062
Mailing Address - Fax:
Practice Address - Street 1:775 MAIN ST
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06615-7406
Practice Address - Country:US
Practice Address - Phone:203-377-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-29
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3090152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist