Provider Demographics
NPI:1619979671
Name:PUCCIA, VINCENT (MD)
Entity Type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:
Last Name:PUCCIA
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 1:1818 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47804-4021
Mailing Address - Country:US
Mailing Address - Phone:812-232-1123
Mailing Address - Fax:812-232-1409
Practice Address - Street 1:1818 N 6TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47804-4021
Practice Address - Country:US
Practice Address - Phone:812-232-1123
Practice Address - Fax:812-232-1409
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-02
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042714208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN020024123OtherMEDICARE RAILROAD
IN100373320AMedicaid
INF87978Medicare UPIN
IN100373320AMedicaid