Provider Demographics
NPI:1013957059
Name:MATTUCCI, KENNETH F (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:F
Last Name:MATTUCCI
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 1:11 NOME DR
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11797-3404
Mailing Address - Country:US
Mailing Address - Phone:516-367-4281
Mailing Address - Fax:516-367-3134
Practice Address - Street 1:29 BARSTOW RD
Practice Address - Street 2:SUITE 203
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-2209
Practice Address - Country:US
Practice Address - Phone:516-482-7960
Practice Address - Fax:516-482-4122
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY096685174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB19998Medicare UPIN
NY09080111Medicare ID - Type Unspecified