Provider Demographics
NPI:1285617019
Name:SCALCUCCI, RICKY L (OD)
Entity type:Individual
Prefix:
First Name:RICKY
Middle Name:L
Last Name:SCALCUCCI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 1ST ST
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-4754
Mailing Address - Country:US
Mailing Address - Phone:715-261-8500
Mailing Address - Fax:715-261-8665
Practice Address - Street 1:800 1ST ST
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-4754
Practice Address - Country:US
Practice Address - Phone:715-261-8500
Practice Address - Fax:715-261-8665
Is Sole Proprietor?:No
Enumeration Date:2005-11-25
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2204152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38576100Medicaid
WI38576100Medicaid
WI39155Medicare ID - Type Unspecified