Provider Demographics
NPI:1669429130
Name:CUCULINO, GREGORY (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:CUCULINO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:GREGORY
Other - Middle Name:P
Other - Last Name:CUCULINO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:222 S PENINSULA DR
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32118-4422
Mailing Address - Country:US
Mailing Address - Phone:386-310-2160
Mailing Address - Fax:386-310-2106
Practice Address - Street 1:222 S PENINSULA DR
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32118-4422
Practice Address - Country:US
Practice Address - Phone:386-310-2160
Practice Address - Fax:386-310-2106
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-28
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD067278L207P00000X
FLME131250207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001754621Medicaid
G89415Medicare UPIN