Provider Demographics
NPI:1245334473
Name:MUCCIOLO, ROBERT L (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
Last Name:MUCCIOLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:20 HICKSVILLE RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-5819
Mailing Address - Country:US
Mailing Address - Phone:516-541-5500
Mailing Address - Fax:516-541-5199
Practice Address - Street 1:20 HICKSVILLE RD
Practice Address - Street 2:SUITE 3
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-5819
Practice Address - Country:US
Practice Address - Phone:516-541-5500
Practice Address - Fax:516-541-5199
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-08
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY148353208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC11797Medicare UPIN
NY68D222Medicare PIN