Provider Demographics
NPI:1124138672
Name:BUCCIGROSS, RICHARD L (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:L
Last Name:BUCCIGROSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4355 HORTENSIA ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-1161
Mailing Address - Country:US
Mailing Address - Phone:858-565-0900
Mailing Address - Fax:619-296-8755
Practice Address - Street 1:4355 HORTENSIA ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103
Practice Address - Country:US
Practice Address - Phone:858-565-0900
Practice Address - Fax:619-296-8755
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG311852084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G311850Medicaid
CAG31185Medicare ID - Type Unspecified
CA00G311850Medicaid