Provider Demographics
NPI:1770724635
Name:BUCCILLI, ANDREA M (MD)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:M
Last Name:BUCCILLI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 PROFESSIONAL PKWY
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14094-5366
Mailing Address - Country:US
Mailing Address - Phone:716-434-7505
Mailing Address - Fax:716-439-9084
Practice Address - Street 1:70 PROFESSIONAL PKWY
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094-5366
Practice Address - Country:US
Practice Address - Phone:716-434-7505
Practice Address - Fax:716-439-9084
Is Sole Proprietor?:No
Enumeration Date:2009-03-23
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY2517621207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03118054Medicaid
NY03118054Medicaid