Provider Demographics
NPI:1619970530
Name:PUCILLO, ANTHONY L (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:L
Last Name:PUCILLO
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:PO BOX 28064
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-8064
Mailing Address - Country:US
Mailing Address - Phone:914-593-7880
Mailing Address - Fax:914-593-7881
Practice Address - Street 1:19 BRADHURST AVE
Practice Address - Street 2:STE 700
Practice Address - City:HAWTHORNE
Practice Address - State:NY
Practice Address - Zip Code:10532-2140
Practice Address - Country:US
Practice Address - Phone:914-593-7800
Practice Address - Fax:914-593-7857
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY139259207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00791997Medicaid
NY060023510OtherRAIIL ROAD MEDICARE
NYA400061871Medicare PIN
NY060023510OtherRAIIL ROAD MEDICARE
NY00791997Medicaid
NY03D881Medicare ID - Type Unspecified
NYA400061871Medicare PIN
NY03D883K222OtherPTAN