Provider Demographics
NPI:1760002810
Name:PUCCIO, BENJAMIN JOHN
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:JOHN
Last Name:PUCCIO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 FEATHER LN
Mailing Address - Street 2:
Mailing Address - City:OLD TAPPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07675-7106
Mailing Address - Country:US
Mailing Address - Phone:551-204-1728
Mailing Address - Fax:
Practice Address - Street 1:90 BERGEN ST STE 5200
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-2425
Practice Address - Country:US
Practice Address - Phone:973-972-5209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-19
Last Update Date:2020-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program