Provider Demographics
NPI:1578637104
Name:MUCCIOLO, PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:
Last Name:MUCCIOLO
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 1:1530 CORNERSTONE BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-7129
Mailing Address - Country:US
Mailing Address - Phone:386-274-7936
Mailing Address - Fax:386-274-7937
Practice Address - Street 1:1530 CORNERSTONE BLVD STE 120
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-7129
Practice Address - Country:US
Practice Address - Phone:386-310-2160
Practice Address - Fax:386-310-2106
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0069281207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL252127000Medicaid
FLG60183Medicare UPIN
FL41426YMedicare PIN