Provider Demographics
NPI:1932151453
Name:COLUCCI, MATTHEW F (PT)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:F
Last Name:COLUCCI
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 DIXIE LN
Mailing Address - Street 2:
Mailing Address - City:EAST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11730-2518
Mailing Address - Country:US
Mailing Address - Phone:516-380-8450
Mailing Address - Fax:631-650-1791
Practice Address - Street 1:15 DIXIE LN
Practice Address - Street 2:
Practice Address - City:EAST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11730-2518
Practice Address - Country:US
Practice Address - Phone:516-380-8450
Practice Address - Fax:631-650-1791
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011517-12251G0304X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS66920Medicare UPIN
NYQ79112Medicare PIN