Provider Demographics
NPI:1790810232
Name:FUNICELLI, MARIO
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:FUNICELLI
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 1:1931 RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-3889
Mailing Address - Country:US
Mailing Address - Phone:718-477-9300
Mailing Address - Fax:718-477-9301
Practice Address - Street 1:1931 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3889
Practice Address - Country:US
Practice Address - Phone:718-477-9300
Practice Address - Fax:718-477-9301
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX007427-1111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN0400XChiropractic ProvidersChiropractorNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX65961Medicare ID - Type Unspecified