Provider Demographics
NPI:1871633719
Name:BUCOLO, PAUL (MD)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:
Last Name:BUCOLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:PAUL
Other - Middle Name:J
Other - Last Name:BUCOLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:250 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-5094
Mailing Address - Country:US
Mailing Address - Phone:321-268-6868
Mailing Address - Fax:321-267-2713
Practice Address - Street 1:125 FLORIDA MEMORIAL PKWY STE 2200
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-9309
Practice Address - Country:US
Practice Address - Phone:386-409-6839
Practice Address - Fax:386-409-6916
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3476363AM0700X
FLPA3476207Q00000X
FLME143433207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290408000Medicaid