Provider Demographics
NPI:1457354771
Name:MAZZUCCHI, FULVIO (MD)
Entity Type:Individual
Prefix:
First Name:FULVIO
Middle Name:
Last Name:MAZZUCCHI
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 1:1279 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2583
Mailing Address - Country:US
Mailing Address - Phone:631-727-2100
Mailing Address - Fax:631-727-2646
Practice Address - Street 1:1279 E MAIN ST
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2583
Practice Address - Country:US
Practice Address - Phone:631-727-2100
Practice Address - Fax:631-727-2646
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY165611207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01340225Medicaid
NY01340225Medicaid
NYA100001194Medicare PIN