Provider Demographics
NPI:1285727529
Name:MUCCINO, GARY PETER (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:PETER
Last Name:MUCCINO
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 1:300 PARKER AVE
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07011-1456
Mailing Address - Country:US
Mailing Address - Phone:973-546-6844
Mailing Address - Fax:973-546-7707
Practice Address - Street 1:300 PARKER AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07011-1456
Practice Address - Country:US
Practice Address - Phone:973-546-6844
Practice Address - Fax:973-546-7707
Is Sole Proprietor?:No
Enumeration Date:2006-10-01
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMAO3527700207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJC55066Medicare UPIN
NJ450359Medicare PIN