Provider Demographics
NPI:1801948302
Name:BUCCIARELLI, NANCY (MD)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:BUCCIARELLI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:668 N COAST HWY
Mailing Address - Street 2:SUITE 1339
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-1513
Mailing Address - Country:US
Mailing Address - Phone:949-464-0470
Mailing Address - Fax:949-464-0720
Practice Address - Street 1:24401 CALLE DE LA LOUISA
Practice Address - Street 2:SUITE 200
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3623
Practice Address - Country:US
Practice Address - Phone:949-464-0470
Practice Address - Fax:949-464-0720
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG593222085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB22951OtherMEDICARE GROUP PTAN
CACB225510OtherMEDICARE INDIVIDUAL PTAN
CA00G593220OtherBS
CAWG59322RMedicare PIN
CAF28835Medicare UPIN