Provider Demographics
NPI:1194793299
Name:BERTUCCI, PHILIP L (MD)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:L
Last Name:BERTUCCI
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 1:431 BERTUCCI BLVD
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39531-2255
Mailing Address - Country:US
Mailing Address - Phone:228-385-2020
Mailing Address - Fax:228-388-9435
Practice Address - Street 1:431 BERTUCCI BLVD
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-2255
Practice Address - Country:US
Practice Address - Phone:228-385-2020
Practice Address - Fax:228-388-9435
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13141207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00122437Medicaid
MS4352630001Medicare NSC
MS4352630003Medicare NSC
MSE76363Medicare UPIN
MS180000225Medicare ID - Type Unspecified