Provider Demographics
NPI:1154309888
Name:BUCCIERO, GEORGE V (DPM)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:V
Last Name:BUCCIERO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 967
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-0967
Mailing Address - Country:US
Mailing Address - Phone:708-532-6029
Mailing Address - Fax:
Practice Address - Street 1:150 E HURON ST
Practice Address - Street 2:SUITE 801
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2999
Practice Address - Country:US
Practice Address - Phone:312-337-2468
Practice Address - Fax:312-337-6912
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-04
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003552213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016003552Medicaid
ILL93801Medicare PIN
ILY38240Medicare UPIN
IL480014973Medicare PIN