Provider Demographics
NPI:1639275266
Name:BELLUCCI, KENNETH (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:BELLUCCI
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 1:1445 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TEWKSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01876-4723
Mailing Address - Country:US
Mailing Address - Phone:978-851-3818
Mailing Address - Fax:
Practice Address - Street 1:1445 MAIN ST
Practice Address - Street 2:
Practice Address - City:TEWKSBURY
Practice Address - State:MA
Practice Address - Zip Code:01876-4723
Practice Address - Country:US
Practice Address - Phone:978-851-3818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2886152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA03119OtherSPECTERA
MA34922OtherDAVIS VISION
MA0341584Medicaid
MAW15536OtherBLUE CROSS/BLUE SCHIELD
MA152049OtherHARVARD HEALTH CARE
MA705042OtherTUFTS HEALTH CARE
MA705042OtherTUFTS HEALTH CARE