Provider Demographics
NPI:1790920312
Name:KENNETH F MATTUCCI MDPC
Entity Type:Organization
Organization Name:KENNETH F MATTUCCI MDPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:F
Authorized Official - Last Name:MATTUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-482-7960
Mailing Address - Street 1:29 BARSTOW RD
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-2209
Mailing Address - Country:US
Mailing Address - Phone:516-482-7690
Mailing Address - Fax:516-482-4122
Practice Address - Street 1:29 BARSTOW RD
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-2209
Practice Address - Country:US
Practice Address - Phone:516-482-7690
Practice Address - Fax:516-482-4122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-10
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY096685207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty