Provider Demographics
NPI:1659397743
Name:PIRRUCCELLO, MICHAEL ROSS (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ROSS
Last Name:PIRRUCCELLO
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 1:3400 DATA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2081 BRONZE STAR DR
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95776-5423
Practice Address - Country:US
Practice Address - Phone:530-666-1631
Practice Address - Fax:530-661-1081
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG42813207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G428130Medicaid
CAAS607ZMedicare PIN
CA00G428130OtherBLUE SHIELD
A49127Medicare UPIN
CA080086117OtherRR MEDICARE
CA00G428130Medicare ID - Type Unspecified