Provider Demographics
NPI:1760446744
Name:COLUCCIO, NICOLE D (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:D
Last Name:COLUCCIO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1365 WASHINGTON AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12206-1068
Mailing Address - Country:US
Mailing Address - Phone:518-489-4446
Mailing Address - Fax:518-489-4448
Practice Address - Street 1:1365 WASHINGTON AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12206-1068
Practice Address - Country:US
Practice Address - Phone:518-489-4446
Practice Address - Fax:518-489-4448
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY232155207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10087875OtherCDPHP PROVIDER #
NYP00294582OtherRAILROAD MEDICARE
NY782072OtherMVP PROVIDER #
NYP00294582OtherRAILROAD MEDICARE
NYRA5337Medicare ID - Type Unspecified