Provider Demographics
NPI:1942317680
Name:COLUCCELLI, GERARD A (MD)
Entity Type:Individual
Prefix:
First Name:GERARD
Middle Name:A
Last Name:COLUCCELLI
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 1:931 BROOKWOOD RD
Mailing Address - Street 2:900
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-4211
Mailing Address - Country:US
Mailing Address - Phone:904-399-0441
Mailing Address - Fax:
Practice Address - Street 1:931 BROOKWOOD RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-4211
Practice Address - Country:US
Practice Address - Phone:904-399-0441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME39542207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL15671OtherBCBS
FL180000739OtherRAILROAD MEDICARE
FL4045150OtherAETNA
FL15671OtherBCBS
FL4045150OtherAETNA
FL15671WMedicare PIN