Provider Demographics
NPI:1659311348
Name:MATTEUCCI, GERALD A (MD)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:A
Last Name:MATTEUCCI
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 1:4135 BOARDMAN-CANFIELD ROAD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-7010
Mailing Address - Country:US
Mailing Address - Phone:330-286-5330
Mailing Address - Fax:330-286-5396
Practice Address - Street 1:1044 BELMONT AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44504-1006
Practice Address - Country:US
Practice Address - Phone:330-286-5330
Practice Address - Fax:330-286-5396
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-056325207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH050090936OtherMEDICARE RAILROAD
OH0770189Medicaid
OHE62243Medicare UPIN
OHMA0672251Medicare ID - Type Unspecified