Provider Demographics
NPI:1972554053
Name:IANNUCCILLI, MICHAEL RAYMOND (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:RAYMOND
Last Name:IANNUCCILLI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2921 ERIE BLVD EAST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13224
Mailing Address - Country:US
Mailing Address - Phone:315-445-7465
Mailing Address - Fax:315-445-7675
Practice Address - Street 1:553 KINGSTOWN RD
Practice Address - Street 2:OPTOMETRIC PROVIDERS OF RHODE ISLAND, INC
Practice Address - City:WAKEFIELD
Practice Address - State:RI
Practice Address - Zip Code:02879-3600
Practice Address - Country:US
Practice Address - Phone:401-782-2100
Practice Address - Fax:401-848-7402
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIODTA00323152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T53394Medicare UPIN