Provider Demographics
NPI:1679572739
Name:PUCCI, RICHARD A (DO)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:A
Last Name:PUCCI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:61 N MAPLE AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-3255
Mailing Address - Country:US
Mailing Address - Phone:201-447-2808
Mailing Address - Fax:201-447-2809
Practice Address - Street 1:61 N MAPLE AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-3255
Practice Address - Country:US
Practice Address - Phone:201-447-2808
Practice Address - Fax:201-447-2809
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-20
Last Update Date:2009-09-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY232242208600000X
NJ25MB07801000208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
I21099Medicare UPIN
NY3543H1Medicare PIN