Provider Demographics
NPI:1922085232
Name:SCUCCIMARRA, DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:SCUCCIMARRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 CLOCKTOWER COMMONS
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:NY
Mailing Address - Zip Code:10509
Mailing Address - Country:US
Mailing Address - Phone:845-279-5187
Mailing Address - Fax:845-279-5168
Practice Address - Street 1:111 CLOCKTOWER COMMONS
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:NY
Practice Address - Zip Code:10509
Practice Address - Country:US
Practice Address - Phone:845-279-5187
Practice Address - Fax:845-279-5168
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY123540208D00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00232375Medicaid
NY293901Medicare ID - Type Unspecified
293901Medicare PIN
NY00232375Medicaid