Provider Demographics
NPI:1285602904
Name:PUCCINELLI, PAMELA L (OD)
Entity type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:L
Last Name:PUCCINELLI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3436 HILLCREST AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94531-6304
Mailing Address - Country:US
Mailing Address - Phone:925-778-5688
Mailing Address - Fax:925-778-8708
Practice Address - Street 1:3436 HILLCREST AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94531-6304
Practice Address - Country:US
Practice Address - Phone:925-778-5688
Practice Address - Fax:925-778-8708
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9548T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CH672AMedicare PIN
CA46748Medicare UPIN
CACA9548Medicare UPIN
SD0095481Medicare PIN
CACH672AOtherMEDICARE PTAN