Provider Demographics
NPI:1942237441
Name:TUCCILLO, MARK W (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:TUCCILLO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2120
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:AK
Mailing Address - Zip Code:99833-2120
Mailing Address - Country:US
Mailing Address - Phone:907-772-3975
Mailing Address - Fax:
Practice Address - Street 1:103 FRAM STREET
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:AK
Practice Address - Zip Code:99833-0589
Practice Address - Country:US
Practice Address - Phone:907-772-4299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAA2935207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine