Provider Demographics
NPI:1932182938
Name:BUCCELLATO, LAURA ANN (OD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:ANN
Last Name:BUCCELLATO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MRS
Other - First Name:LAURA
Other - Middle Name:ANN
Other - Last Name:GILLESPIE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:388 HAWKINS AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-4280
Mailing Address - Country:US
Mailing Address - Phone:631-588-7004
Mailing Address - Fax:631-588-2612
Practice Address - Street 1:388 HAWKINS AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-4280
Practice Address - Country:US
Practice Address - Phone:631-588-7004
Practice Address - Fax:631-588-2612
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV6227-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7002866OtherCIGNA
NYC407A1OtherEMPIRE
NYP3585214OtherOXFORD
NY6599232OtherGHI
NYCDWGG1OtherPTAN MEDICARE
NY2529608OtherUNITED HEALTHCARE
NYU86396Medicare UPIN
NYP3585214OtherOXFORD
NY2529608OtherUNITED HEALTHCARE