Provider Demographics
NPI:1831489111
Name:BUCCAFUSCO, MILDRED JEAN (PTA)
Entity Type:Individual
Prefix:MS
First Name:MILDRED
Middle Name:JEAN
Last Name:BUCCAFUSCO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4050 NOSTRAND AVE
Mailing Address - Street 2:APT. 2C
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-2250
Mailing Address - Country:US
Mailing Address - Phone:718-496-8051
Mailing Address - Fax:718-368-2669
Practice Address - Street 1:420 95TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-7404
Practice Address - Country:US
Practice Address - Phone:718-680-9751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-08
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001-5161225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant